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Get OptumRx C0009 PDP2491E 0001

form with the original prescription label receipt(s) within 90 days. Please make and retain a copy of the receipts for your records. Cash register and credit card receipts alone are not acceptable as proof of purchase. Claims are reviewed, subject to limitations, exclusions and other provisions of the Plan Benefit. Reimbursement is not guaranteed. Patient Information (Complete one form per member) Health Plan/Insurance Name & State (please print) Group Employer/Name Name (Last Name, First Na.

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