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Get MAPD PRESCRIPTION REIMBURSEMENT REQUEST FORM

Ad the Acknowledgement (Section 4) on the front of this form carefully. Then sign and date. Print page 2 of this form on the back of page 1. 3. Send completed form with pharmacy receipt(s) to: OptumRx Claims Department, P.O. Box 29045, Hot Springs, AR 71903. Note: Cash and credit card receipts are not proof of purchase. Incomplete forms may be returned and delay reimbursement. Reimbursement is not guaranteed. Claims are subject to your plan s limits, exclusions and provisions. Section A.

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