Filing a Medicare Part D drug claim

Page last updated on: 3/07/25

How to file a claim and get reimbursed

Complete the form to file a claim for your Medicare Part D drug and provide the following required information based on your reason for reimbursement.

For prescriptions or vaccines filled at a pharmacy:

  • A pharmacy printout
  • Proof of payment or receipt

For self-administered drugs (SADs) or vaccines that were received during outpatient care or at your physician's office:

  • A bill or itemized statement from the provider
  • The NDC (National Drug Code) information for medication or vaccine

Don't forget to submit your form. Once it's completed, follow the directions at the bottom of your form to submit it.

When to use this form

If you paid out of pocket or received a bill for any of the following Medicare Part D benefits:

Prescriptions that you purchased at your pharmacy without using your insurance card.

These are drugs you received in the emergency room or during observation at the hospital, that you would normally take on your own either orally, topically, through an injection, or by inhaling it. You usually get these drugs at a pharmacy however these drugs can also be given to you in an outpatient setting.

Vaccines that you purchased at a pharmacy without your member ID card or vaccines you received at your physician's office.

Y0056_NCMS400040062200A_C 10052021