Get Optumrx Reimbursement Form

This guide provides step-by-step instructions on completing the Optumrx Reimbursement Form online. Following these directions will help ensure your request for reimbursement is processed smoothly and efficiently.

Follow the steps to accurately complete the reimbursement form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the member information section. This includes providing details such as your RxGroup and Member ID, which can be found on your ID card. Clearly print your last name, first name, and middle initial. Enter your mailing street address, city, state, and ZIP code. Indicate whether the prescription is for yourself, a spouse, or a dependent. Additionally, include your date of birth and gender.
3. If you are the custodial parent requesting reimbursement for a child under the age of 18, complete the custodial parent information section. This includes the legal custodian's name, contact phone number, and address where payment should be sent. Ensure you meet the eligibility requirements outlined.
4. In the physician and pharmacy information section, provide the prescribing physician's name and phone number, as well as the dispensing pharmacy's name and contact number. Next, select the suitable reason for your reimbursement request from the provided options.
5. Review the acknowledgment section. You must certify that the requested medications were received, are for the patient mentioned, and are not for on-the-job injuries. Sign and date this section to confirm your acknowledgment.
6. After completing the form, attach the original pharmacy receipts for each medication. Verify that each receipt contains all required information as outlined in Section A.
7. Once all sections are complete, print page 2 of the form if applicable, and ensure that your submission is free from errors. Then, send the completed form along with the pharmacy receipts to the specified address: OptumRx Claims Department, P.O. Box 29044, Hot Springs, AR 71903.
8. Make sure you retain copies of the completed form and receipts for your records. Monitor your submission for any updates or requests for additional information.

Take the next step and complete your Optumrx Reimbursement Form online today!