Get Printable Optumrx Refill Forms

Filling out the Printable Optumrx Refill Forms online is a straightforward process that allows you to submit requests for reimbursement quickly and efficiently. This guide will provide you with detailed instructions on how to complete the form accurately, ensuring that you meet all necessary requirements.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Complete the Patient Information section by entering your health plan or insurance name and state, group employer or name, your last name, first name, and middle initial, birth date, ID number, mailing address, prescribing physician's name, DEA or NPI number, and physician's telephone number.
3. In the Reason for Request field, write a clear and concise reason for submitting the claim.
4. If applicable, fill out the Coordination of Benefits section with your primary health plan or insurance company name and the primary member/subscriber's name.
5. For Vaccine and Vaccine Administration, check all relevant options that apply to your claim regarding the cost of administration and the location where it was filled and administered.
6. If your claim involves a compound prescription, list each valid 11-digit NDC number along with the corresponding metric quantity and total charge paid by you.
7. Sign the form at the designated area, certifying that the information provided is accurate and that the claim pertains to a covered person in the Prescription Drug Program.
8. Once all sections are completed, ensure that you have included the original prescription label receipts, which must include specific information, and keep copies for your records.
9. Finally, mail the completed form along with the receipts to the address provided: OptumRx, P.O. Box 29045, Hot Springs, AR 71903. You may also choose to save changes, print the form, or share as needed.

Complete your Printable Optumrx Refill Forms online today for a hassle-free reimbursement process.