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PRESCRIPTION BENEFIT PROGRAMMER SELF REIMBURSEMENT FORMCARDHOLDER PATIENT INFORMATION EMPLOYER NUMEROUS NAMECARDHOLDER NAME (Last Name, First Name, M.I.)GROUP NUMBER (from I.D. Card)CARDHOLDER IDENTIFICATION
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First, log in to the healthbenefitsprogramks.gov website.
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Who needs healthbenefitsprogramksgovmediacmsprescription benefit program member?

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Individuals who require prescription medications on a regular basis and are eligible for the healthbenefitsprogramks.gov prescription benefit program may need to fill out the form as a member.
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The health benefits program for Kansas residents offers support for prescription costs to eligible members, ensuring access to necessary medications.
Eligible individuals enrolled in the health benefits program are required to file for the prescription benefit program.
To fill out the form, members need to provide personal information, details about their medications, and any other required documentation as specified in the application instructions.
The purpose of the program is to provide financial assistance for prescription medications to reduce the burden of healthcare costs on eligible individuals.
Members must report personal identification details, current income, medication information, and any other relevant health data as required by the program.
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