Submitting a Reimbursement Request Via Paper Form
This article applies to you if you have a Via Benefits reimbursement account (sometimes known as a Health Reimbursement Arrangement)*.
You can submit a paper Reimbursement Request Form; however, it's not the preferred method of submission. It’s less secure and may take up to 10 days longer than submitting your request on the website or on the mobile app.
To request reimbursement by mail, follow these steps:
1. Call us at 1-866-322-2824 (TTY: 711) and use our automated voice system to request a form if you don’t have one.
2. Complete the Reimbursement Request Form to request reimbursement for premiums or out-of-pocket expenses if allowed by your former employer.
3. Mail the completed form and the required supporting documents to the address provided on the form.
Once we receive your reimbursement form, allow five business days for it to be processed.
Note: If you’ve turned on Automatic Premium Reimbursement (Medicare only), don’t submit a reimbursement request for the same premiums.
Forms are personalized with your information and have a barcode specific to the account holder. Forms can be used to submit requests for eligible dependents associated with the account holder. Submitting requests for ineligible dependents or using a form barcoded for another account holder may result in a delayed or denied reimbursement.
If you and your spouse have separate accounts:
Don’t share your personalized reimbursement forms with your spouse; you and your spouse must submit separate, personalized forms.
Don’t alter a personalized form. Instead, call us and use the automated voice system to request a new form.
The Catastrophic Coverage Reimbursement Request Form and Special Payment Benefit Form are only available by calling Via Benefits. These reimbursement benefits are available to you if offered by your former employer or benefits provider.
Good news! Beginning January 1, 2024, you won’t need to pay a copay in the catastrophic coverage phase of your prescription drug plan due to the Inflation Reduction Act of 2023. You can still get reimbursed for catastrophic prescription expenses you incurred before January 1, 2024, and you will have between 3 and 12 months in 2024 to submit those expenses. The Via Benefits website displays a message with your specific expense submission deadline.
Form Explanation
*Via Benefits reimbursement accounts are administered by Extend Health, LLC.