Submit a Claim
If you are a member and have a prescription you paid for and need to have processed for reimbursement, print this page (or you may download the form as a PDF or Word Document), complete the following information and return it to the Prescription Network office. Your request for reimbursement MUST be accompanied by a copy of the prescription claim receipt (NOT a cash register receipt) in order for your claim to be processed:
 

Employer Group:		___________________________________________
Cardholder Name:		___________________________________________
Cardholder ID Number:		___________________________________________
Patient Name:		___________________________________________

Address where reimbursement should be sent: (reimbursement check will be made out to the Cardholder, regardless of the address you supply):

____________________________________________________________________________

____________________________________________________________________________


Phone Number: ___________________________________
(This will only be used in the event we have questions about your claim).
 

ATTACH A COPY OF THE PRESCRIPTION RECEIPT(S) WHICH YOU ARE REQUESTING REIMBURSEMENT ON.

Submit this completed form, along with your receipt copies to:
 

Mail: Prescription Network 1020 SW Fairlawn Rd Topeka, KS 66604

Fax:  785-228-9147

If you have any questions, contact the Prescription Network office at 1-800-279-3022.

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