MightyWELL Health Plan Prescription Claim

MightyWELL Health Plan

Prescription Claim Form
Primary Insured's Information
Primary Insured’s Full Name*
Primary Insured’s Email*
Primary Insured’s Phone #*
Date of birth*

MonthDayYear
Date
Patient’s Full Name*
POLICY*
Prescription Information
Prescribing Physician*
Name of Medication*
Amount Paid*
RX #*
Treated Condition*
Date filled*

MonthDayYear
Date
# of Days Supplied*
Receipt Upload

Attach the RX (prescription) receipt. It must include the Rx name, dosage, client name, pharmacy, date, and AMOUNT paid.
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MightyWELL Representative
Representative Name
Representative Email
Representative Phone #
**Prescriptions for Pre-Existing conditions are not reimbursable until after the first 12-months of health coverage. Please contact your agent with any questions.**

**Reimbursement checks are typically mailed within 14 business days after receipt of claim**
Should be Empty:

MightyWELL Health Plan