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Pharmacy & Medical Claims


The DSGHP has retained HealthSmart to perform claims processing and other specified services in relation to DSGHP coverage. Based in Fairlawn, Ohio HealthSmart has been in the benefits administration business for over 25 years. Their clients are self-funded employers with locations throughout the United States, representing a wide range of private sector as well as public sector employers and school districts. In addition to self-funded employers, HealthSmart provides the administration for many fully-insured university student health plans. These plans provide health care coverage for nearly 80,000 students enrolled in some of the country‚Äôs most prestigious colleges and universities.

Submit claims to: Cigna PPO, PO Box 188061, Chattanooga, TN 37422-8061
Phone: (800) 331-1096

Medical Claim Form

Express Scripts

Prescription Drug benefits are payable in connection with covered prescriptions and refills dispensed by licensed pharmacists. Although a physician's prescription is required, fulfilling this requirement does not guarantee that a particular drug will be covered.

The DSGHP utilizes Express Scripts for the administration of its Prescription Drug Benefits. Express Scripts has a nation-wide network of participating pharmacies. The Dartmouth Health Services Pharmacy is a member of the Express Scripts Pharmacy network.

When you fill a covered prescription at a Network Pharmacy and show your Plan Identification card with the Express Scripts logo, the Pharmacy will submit the claim on your behalf and accept the network maximum allowable cost as full payment. You will pay only your share of the expense, which may include the Prescription plan year deductible, your coinsurance, or a combination of the two.

When you fill a covered prescription at a Pharmacy outside the Network, you must pay for the full cost of the purchase and then submit a claim for benefits to Express Scripts for reimbursement.

Non-Express Scripts Network Pharmacies may charge you more than the network maximum allowable cost. Charges in excess of the network maximum allowable cost are not covered by the DSGHP.

Prescription Claim Form

Last Updated: 6/26/15