Part D Claim form

2023

For Medicare Part D drug claims, please complete this form and mail with receipts to:

Express Scripts
ATTN: Medicare Part D
PO Box 14718
Lexington, KY 40512-4718

Or

Fax completed form with receipts to: 1-608-741-5483

2024

For Medicare Part D drug claims, please complete this form and mail with receipts to:

Navitus Health Solutions Manual Claims
PO Box 1039
Appleton, WI 54912-1039

Or

Fax completed form with receipts to: 1-855-668-8550