There are different forms for requesting a reimbursement of different out-of-pocket expenses. Please read the following descriptions to determine the correct form to use for your current situation.  Download the correct form from the Related Documents list on the right side of the page.

2019 Wellness Wallet Reimbursement Request (4/1/19)
2020 Wellness Wallet Reimbursement Request
This form is for any services covered under your Wellness Wallet reimbursement benefit. See the Wellness Wallet page for more details on the fitness and wellness services and equipment covered under this benefit.

Reimbursement Request for Medical Services
This form is for reimbursement for medical services that you received through a provider or at a medical facility.

Reimbursement Request for Medicare Prescription Drug Purchase
This form is the prescription drug reimbursement form.  It is used when you have paid out-of-pocket for your formulary prescription drug.

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