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Member Claim Forms

To request reimbursement for a covered prescription drug purchased at retail cost, you must submit a completed claim reimbursement form to Flipt.

Please read carefully before completing the form. Claim forms that do not include the required information may delay or inhibit our ability to process your request for reimbursement. Completion and submission of this form do not guarantee reimbursement. Claims are subject to limitations, exclusions, and other provisions of your benefit plan. Reimbursement claims are researched and processed once all information has been received. Once all information is received, it takes up to 30 days to make a reimbursement determination. 

Please send your completed form to Flipt via fax at 1-551-430-5669 OR email at