Get Optumrx Direct Member Reimbursement Form

Filling out the Optumrx Direct Member Reimbursement Form online is a straightforward process. This guide will walk you through each section of the form, ensuring you provide the necessary information for a successful reimbursement request.

Follow the steps to complete your reimbursement request effectively.

1. Press the ‘Get Form’ button to access the Optumrx Direct Member Reimbursement Form and open it in your document editor.
2. In the Patient Information section, provide the health plan or insurance name and state, group name, and HIC number. Fill in your name, birth date, prescriber ID number, and mailing address, ensuring all details are accurate.
3. Fill out the Prescribing Physician's Information by including their name, DEA or NPI number (which you should obtain from the physician), and their telephone number.
4. In the Reason for Request section, clearly state the reason for your reimbursement request, ensuring it aligns with your purchased prescription drug.
5. If applicable, complete the Coordination of Benefits section, providing the name of your primary health plan or insurance company and the primary member/subscriber's name. Attach an Explanation of Payment from your primary insurance that indicates the dollar amount paid.
6. If your claim involves vaccines, indicate whether the vaccine was filled and/or administered at a pharmacy or a physician's office. Check all relevant boxes.
7. For compound prescriptions, list each valid 11-digit NDC number corresponding to the ingredients used in the prescription, followed by their quantities.
8. Indicate the total charge paid by you for the prescription, ensuring to include all necessary receipt(s) as proof of purchase.
9. Sign the form as the member/subscriber, certifying that all information provided is correct and acknowledging any necessary releases of information.
10. Before submitting, review the form for completeness and accuracy. Save any changes, download a copy for your records, and print the form as needed.
11. Mail the completed form along with the required receipts to Prescription Solutions at the address provided in the instructions.

Complete your Optumrx Direct Member Reimbursement Form online today to ensure a smooth reimbursement process.