PRESCRIPTION DRUG CLAIM FORM

HSRX Claim FormIf you are currently obtaining a prescription medication at a retail pharmacy that is not part of the HealthSmartRx network, please contact provider relations at 800.681.6912 and request that your pharmacy be added to the network. If you fail to present your new prescription drug card or use a non-network pharmacy, you will be required to pay the total cost of the prescription drug at a non-discounted rate. To submit a prescription claim for payment, click on the Prescription Drug Claim Form (below) to open a PDF of the form and then print, complete and mail the form to HealthSmart Rx at the address below:

Click on the Prescription Drug Claim Form at right. Complete and mail to HealthSmart Rx at the address below:

  • HealthSmart Rx
  • 3320 West Market St
  • Fairlawn, OH 44333