CSTA Prescription Reimbursement Form
Please complete this form and mail pharmacy receipts (with medications blacked out) to: CSTA, PO Box 75, Central Square, NY 13036. The deadline for reimbursement is June 1 of each year. (for any receipts dated prior to that date.)

Retail Orders purchases (1 month supply)

$5  for Tier 1 - Note: No reimbursement

$20 for Tier 2 - Note: you will reimbursed $5

$40 for Tier 3 - Note: you will be reimbursed $10

Mail Order purchases (3 month supply)

$10 for Tier 1 - Note: No reimbursement

$40 for Tier 2 - Note: you will reimbursed $10

$80 for Tier 3 - Note: you will be reimbursed $20

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Email *
CSTA Member's Name: *
CSTA Member's Address: *
Home Phone Number: *
Home Email Address: *
Total Number of Prescriptions Eligible for Reimbursement: (You may use this form to request reimbursement for up to five medications.) *
Prescription #1- Pharmacy Name: *
Prescription #1 - Date Prescription Filled: *
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Prescription #1 - The cost of this prescription was: (If you have no other eligible prescriptions, skip the remaining questions and submit the form.) *
Prescription #2 - Pharmacy Name:
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Prescription #2 - Date Prescription Filled:
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Prescription #2 - The cost of this prescription was: (If you have no other eligible prescriptions, skip the remaining questions and submit the form.)
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Prescription #3 - Pharmacy Name:
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Prescription #3 - Date Prescription Filled:
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Prescription #3 - The cost of this prescription was: (If you have no other eligible prescriptions, skip the remaining questions and submit the form.)
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Prescription #4 - Pharmacy Name:
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Prescription #4 - Date Prescription Filled:
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Prescription #4 - The cost of this prescription was: (If you have no other eligible prescriptions, skip the remaining questions and submit the form.)
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Prescription #5 - Pharmacy Name:
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Prescription #5 - Date Prescription Filled:
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DD
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Prescription #5 - The cost of this prescription was: (If you have no other eligible prescriptions, skip the remaining questions and submit the form.)
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