Transportation Reimbursement Submission Request

Trips must be to or from plan-approved locations, such as network providers, medical facilities, pharmacies, or hearing and vision appointments. If a member is privately transported to dialysis service appointments (not using our transportation benefit), the private driver may be reimbursed by our plan. See your evidence of coverage, Chapter 4 benefits chart for more information.

Please fill out the form below and include all information prior to submitting. Claims payments for transportation reimbursement can take up to 14 days.