Express Scripts Manual Claim Form for Retirees Age 65 and Over (Medicare Carveout Plan)
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.12/03/2013 (revision date)
Submit paper form to See form for details