Title
What is this for?
Contact Information
To submit a claim for medical expenses
Kaiser Permanente Insurance Company (KPIC) Self-Funded Claims Administrator
P.O. BOX 30547
Salt Lake City, UT 84130-0547
Phone: (866) 213-3062
To submit a claim for dental services
For mailing address, call Customer Service at number listed on your ID Card
To submit a claim for prescription drugs
Express Scripts, Inc.
P.O. Box 66583
St. Louis, MO 63166-6583
ATTN: NGC STD ACCTS
To request reimbursement for covered medications purchased at retail cost
Send completed form with pharmacy receipt(s) to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
Prescription Claim Form for Medicare Part D
Express Scripts
ATTN: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718
FAX: (608) 741-5483
Out of Network Vision Services Claim Form
EyeMed Vision Care
Attn: OON Claims
P.O. Box 8504
Mason, OH 45040-7111
Group Medicare Advantage (GMA) members requesting reimbursement for covered medical care and supplies. Use for claims claims within, and outside of the US.
Send completed form and paperwork to the address on the back of your member ID card.
Group Medicare Advantage (GMA) members requesting reimbursement for covered medications purchased at retail cost. Use for claims claims within, and outside of the US.
OptumRx Claims Department, P.O. Box 29046, Hot Springs, AR 71903
Submitting international travel claims for Retirees participating in Medicare Supplement plans only
Episcopal Church Medical Trust
Travel Protection Benefit Coordinator
PO Box 2745
New York, NY 10163