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2023 overthecounter (OTC) productORDER FORMS TEP 1 COMPLETE YOUR INFORMATION BELOW OTC Card Program Date of BirthMember ID (found on plan member ID card) First Name Street Numberless Name and SuffixMIStreet

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How to fill out over-form-counter otc reimbursement claim

01

Obtain the OTC reimbursement claim form either online or from your insurance provider.

02

Fill out your personal information including name, address, policy number, and contact information.

03

Provide the details of the OTC items purchased including the name, quantity, and cost of each item.

04

Include any required documentation such as receipts or invoices for the purchased OTC items.

05

Review the completed form for accuracy and make sure all necessary information is provided.

06

Submit the form to your insurance provider either online or by mail.

Who needs over-form-counter otc reimbursement claim?

01

Individuals who have purchased over-the-counter (OTC) items that are eligible for reimbursement through their insurance plan.

02

People who want to be reimbursed for OTC items that are deemed medically necessary.

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What is over-form-counter otc reimbursement claim?

Over-the-counter (OTC) reimbursement claim is a request for reimbursement for eligible OTC medications and health-related products purchased with a flexible spending account (FSA) or health savings account (HSA) funds.

Who is required to file over-form-counter otc reimbursement claim?

Individuals who have purchased eligible OTC medications and health-related products using FSA or HSA funds are required to file OTC reimbursement claim.

How to fill out over-form-counter otc reimbursement claim?

To fill out an OTC reimbursement claim, individuals need to submit a claim form along with receipts showing the purchase of eligible OTC items.

What is the purpose of over-form-counter otc reimbursement claim?

The purpose of OTC reimbursement claim is to provide individuals with a way to receive reimbursement for qualified OTC expenses paid for with FSA or HSA funds.

What information must be reported on over-form-counter otc reimbursement claim?

The information required on an OTC reimbursement claim typically includes the date of purchase, the name of the product purchased, the amount spent, and a receipt showing proof of purchase.

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