Get Optumrx Direct Member Reimbursement Form 2012-2025
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How to fill out the Optumrx Direct Member Reimbursement Form online
The Optumrx Direct Member Reimbursement Form allows users to request reimbursement for covered prescription drugs purchased at retail cost. This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently.
Follow the steps to complete the reimbursement form online
- Click ‘Get Form’ button to obtain the form and open it for editing.
- Fill in your patient information. Provide your health plan or insurance name and state, group employer name, your complete name (last name, first name, middle initial), identification number, mailing address, birth date, prescribing physician's name, and their phone number, as well as their DEA or NPI number.
- State the reason for your reimbursement request in the provided section.
- If applicable, complete the coordination of benefits section, providing the primary insurance details including plan name and the primary member's name along with an explanation of benefits showing the dollar amount paid.
- For compound prescriptions, the pharmacist must fill in the required fields, including listing the valid 11-digit NDC numbers, the date filled, days' supply, quantity, and the total charge for each ingredient.
- Ensure all necessary receipts are attached, as the claim will be reviewed based on the provided documentation. Cash register and credit card receipts alone are insufficient.
- Sign and date the form as a member/subscriber, ensuring your authorization statement is complete for processing.
- Review all entries for accuracy and completeness before saving changes. You can download or print the completed form if required.
- Finally, mail the completed form and all attached receipts to the specified address: Prescription Solutions by OptumRx, P.O. Box 29044, Hot Springs, AR 71903.
Complete your Optumrx Direct Member Reimbursement Form online to request your prescription drug reimbursement today.
When filling out the reimbursement form, start with your basic information such as name, address, and member ID. Clearly describe the medication or service received, including dates and costs. It's essential to provide an accurate account of your expenses, as this will facilitate the reimbursement process. Remember, completeness and accuracy are key to ensure a successful claim using the Optumrx direct member reimbursement form.
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