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Direct Member Reimbursement (DMR) Prescription Claim Form

The Direct Member Reimbursement (DMR) Prescription Claim Form should be used by members who wish to be reimbursed for prescriptions that were filled at a non-participating pharmacy due to an emergency or other unforeseen circumstance.

For example, you go on vacation and develop a sinus infection. You receive a prescription and have it filled at the local pharmacy where you are vacationing. Because the local pharmacy is not a Unity participating pharmacy, you have to pay the full cost of the medication at the pharmacy. When you return from vacation, you complete the DMR to receive reimbursement.

To be reimbursed, follow these steps:

  1. Print the form and attach all receipts for the prescription medications noted on the form.
  2. Mail form and attached receipts to the address indicated on the form.

You will receive reimbursement roughly 4 weeks after the request is received. DMR forms received more than 18 months from the date the prescription was filled are not eligible for reimbursement. Reimbursement is not guaranteed.

Questions?
Call Unity's Pharmacy Department at 800-788-2949 with questions regarding this form or the status of your reimbursement.