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Get Optumrx Prescription Drug Program Medicaid Direct Member Reimbursement Form 2020-2025
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How to fill out the OptumRx Prescription Drug Program Medicaid Direct Member Reimbursement Form online
Filling out the OptumRx Prescription Drug Program Medicaid Direct Member Reimbursement Form online can streamline the process of obtaining reimbursement for your covered prescription drugs. This guide offers a clear, step-by-step approach to assist you in completing the form accurately.
Follow the steps to successfully fill out the form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter your member information in the designated fields, including health plan name, member ID, date of birth, last name, first name, and middle initial.
- Provide your mailing address in the specified section of the form.
- Include your prescribing doctor’s name and phone number as prompted.
- Select at least one reason for your request from the list provided on the form, marking the appropriate box.
- If applicable, fill out the Coordination of Benefits section only if your primary insurance has already paid for the attached prescription.
- Sign the form in the designated area, confirming the statements regarding coverage and eligibility.
- Review the form for accuracy and ensure that all required receipts are included: original prescription label and proof of purchase.
- Once the form is completed, save the changes, and then download or print it for your records.
- Mail the completed form along with any receipts to the address provided: OptumRx, P.O. Box 650334, Dallas, TX 75265-0334.
Complete your documents online today for efficient processing!
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