Claim

Claim Form - Medical (FEP)

Federal Employee Program (FEP) members use this form to file a medical claim. ID: 10407

Claim Form - Medical - Reimbursement - Orally Administered Cancer Medication Coverage

Use this form to request reimbursement for cancer medication. ID: 5337

Dental - Patient Encounter Form

This is a Dental claim form used by the dental provider for patient encounters. ID: 2954

Prescription Drug/COVID-19 At-Home Test Kit Claim Form

Use this claim form to submit eligible pharmacy expenses for reimbursement, including COVID-19 at-home test kits you paid out of pocket for. You have to submit one claim form for each person and each prescription. Full instructions can be found on page 2. ID: 3272 NJ 03/22