Along with your completed claim form, you must submit an itemized receipt that includes the following information:
- Name of the provider
- Date of the purchase
- Name of the item being purchased
- Your out-of-pocket cost for the service
- Your signature on the claim form certifies that the item qualifies as an eligible expense under IRS regulations, is for use by you, your spouse or eligible dependent, and is not reimbursable from any other source.
To be reimbursed for an OTC drug or medicine, a completed claim form must be submitted to Benefit Resource along with one of the following:
- A customer receipt that reflects the date and the amount of the purchase, along with a copy of the prescription from your medical provider or
- A customer receipt identifying the name of the person for whom the prescription applies, the date and amount of the purchase, and the Rx number.
Certain OTC items may require a completed Certification of Medical Necessity form along with your receipt and claim form. Examples can be found in the OTC Chart.