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Reimbursement Forms

General Reimbursement Form

Use our general reimbursement form to get paid back for Wellness Bucks purchases, myFlex plan purchases, and covered medical services you paid for. (For any reimbursements related to Part D prescription drugs, please use the Prescription Drug Reimbursement form below.)

You can also fill out the form online — text PAYMEBACK to 866-85 to let our Guide team know that you’d like to submit a reimbursement.

Note for Flex plan members. If you're using this form for a myFlex purchase, get paid back faster by logging into your myFlex account and making a payment request.

Get the Form

Prescription Drug Reimbursement Form

Use our prescription drug reimbursement form to get paid back for covered medications you paid for.

Get the Prescription Drug Form