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Name *
Best Phone Number *
Email address
Zip code *
Time zone*	Eastern Central Mountain Pacific Other:
What do you need help with? *	Drug pricing (we will need name, dosage and quantity) Pharmacies near you Questions on plan Christian Healthcare Ministries question Other:
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Troubleshooting Form

*Note: Please read alerts before submitting a troubleshooting request.

Please use thes form below if things did not go as expected at the pharmacy. If an error was made in pricing, you will be able to be reimbursed at the pharmacy. The time frame is dictated by the pharmacy, but is typically 7-14 days.

We will need you to furnish the following information so that we may research your claim problem. If you have completed the form, please do not leave a voicemail message unless you have not heard a response in 48 hours.

Name: *
Member ID from card: *
Plan Group # from card: *
Date of Birth: *
Prescription # from bottle:
Medication Name: *
Dosage *
Quantity *
Name of Pharmacy *
Pharmacy Phone # *
Your best phone number: *
Alternate phone
Your email address:
Time zone: *	Eastern Central Mountain Pacific Other:

Was your difficulty related to: *	price increase in previously purchased medication no discount with card card not accepted pharmacy said card is expired price charged was different than website other (please give details)
Additional Details:

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2310 Superior Avenue, Cleveland OH 44114

877-403-8233

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