Health Insurance OTC Medical Expense Reimbursement Claim Form
Submit your OTC medical expense reimbursement claim by providing claimant details, plan reference, claim information, and certification that the expense is accurate and eligible.
Claimant and Member Information
Claimant full name
*
First Name
Middle Name
Last Name
Relationship to insured member
*
Please Select
Self
Spouse
Dependent
Other
Member or insured name (if different)
First Name
Middle Name
Last Name
Health plan or member ID reference
*
Contact phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact email address
example@example.com
Claim Details
Claim submission date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of purchase or service
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
OTC medication or expense category
*
Please Select
Pain relief
Cold and flu
Allergy
Digestive health
First aid
Feminine care
Family planning
Vitamins and supplements
Personal care
Medical supplies
Other
Item or product description
*
Merchant or pharmacy name
Total amount claimed
*
Reimbursement preference
Direct deposit
Check by mail
Plan card credit
No preference
Certification and Submission
Certification of Eligibility and Accuracy
*
1
I confirm that the expenses claimed are eligible OTC medical expenses, have not been reimbursed elsewhere, and that the information provided is true and accurate.
Supporting Receipt or Documentation
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