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Premium Reimbursement Request Form

Premium Reimbursement Request Form

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P.O. Box 489
Buckeystown, MD 21717

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20440 Century Blvd., Suite 250
Germantown, MD 20874

Hours: M-F 9am-5pm EST
Phone: (800) 675-8416
Fax: (800) 282-7692

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When health insurance is not enough.®

501(c)(3) independent non-profit organization providing financial assistance to adults and children to cover the cost of prescription drug coinsurance, copayments, deductibles, health insurance premiums and other selected out-of-pocket health care costs.

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