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  • Manual claim form for employees and retirees under age 65
  • Click to view (pdf or doc)
  • Under some circumstances it may be necessary to manually file a prescription claim.  For example if you are out of town and cannot locate your Express Scripts ID card, it may be necessary to pay for the prescription and manually file for reimbursement once you return.  Please note claims must be filed within twelve (12) months of receiving a prescription.
  • Revision date: 11/15/2019