Use this form to request reimbursement for covered medications purchased at retail cost. Complete one form
per member. Please print clearly. Additional information and instructions on back, please read carefully.
Member Information
Member ID (see ID card) Health Plan Name
Group/Employer Name Health Plan State
Last Name First Name MI
Mailing Street Address Apt. #
City State ZIP Date of Birth
Physician and Pharmacy Information
Prescribing Physician Name Dispensing Pharmacy Name
Prescribing Physician Phone Number with Area Code Dispensing Pharmacy Phone Number with Area Code
Reason for Request
Select appropriate options for your request:
I did not use my prescription drug ID card.
I used a non-participating pharmacy for one of the following reasons:
I traveled outside my plan’s service area and needed my medication but could not access a network pharmacy.
I could not get my medication in a timely manner from either a network pharmacy located within a reasonable
driving distance or a network mail service pharmacy.
A non-network pharmacy located within a care institution (emergency department, provider based clinic,
outpatient surgery or other outpatient facility) dispensed my medication while I was a patient.
I was evacuated or displaced from my residence due to a state or federally declared disaster or health emergency.
I filled a compound prescription (your pharmacist must complete Section B on the back of this form).
My primary coverage is with another insurance carrier (coordination of benefits claim, see Section C on back for details).
I am submitting an Explanation of Benefits (EOB) from another health plan or Medicare.
Primary Health Plan Name: ___________________________________________________
I am submitting a copay receipt.
I was waiting for a drug approval.
I was retroactively enrolled with the plan.
My pharmacy billed the wrong plan.
Vaccine and/or vaccine administration
• Vaccine prescription filled at: Pharmacy Physician’s office
• Vaccine administered by: Pharmacy Physician’s office
• Applicable to cost of claim (select all that apply): Administration cost Vaccine cost
Other (please explain) ___________________________________________________________________________________
I certify that the patient for whom this claim is made is covered in this prescription drug program and that the prescription
is for the sole use of the named patient. I also certify that the claim(s) being submitted for payment are not eligible
for payment under a no-fault automobile or worker’s compensation insurance program. I also authorize release of all
information pertaining to this claim(s) to the plan administrator, underwriter, sponsored policy holder, and/or employer.
X _______________________________________________________________________ _________________________
Member or Authorized Representative Signature
NOTE: If form is completed and signed by an Authorized Representative rather than
the member, an Authorization of Representation (AOR) must accompany the request
or Power of Attorney (POA) must be on file with the plan.
ORX5262E WF1478997
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Instructions for Submitting Form
1. Include the original pharmacy receipt for each medication (not the register receipt). Pharmacy receipts must contain the
information in Section A (below). If you do not have pharmacy receipts, ask your pharmacy to provide them to you.
2. Read 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, PO Box 650287, Dallas, TX 75265-0287.
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 Pharmacy Receipts for Reimbursement
Use the following checklist to ensure your receipts have all information required for your reimbursement request:
Date prescription filled
National Drug Code (NDC) number
Prescription number (Rx number)
Name and address of pharmacy
Name of drug and strength
Prescribing physician name or ID number
Section B – Pharmacy Information (for compound prescriptions ONLY)
(Pharmacist must complete and sign)
List VALID 11 digit NDC number (highest to lowest
cost) in the box at right. Include EACH ingredient
used in the compound prescription.
For each NDC number, indicate the metric quantity
expressed in the number of tablets, grams, milliliters,
creams, ointments, injectables, etc.
Indicate the TOTAL amount paid by the patient.
Receipt(s) must be provided with this claim form.
Individual quantities must equal the total quantity.
Individual ingredient costs plus compounding fees
must be equal to the total ingredient costs.
Signature of Pharmacist
Section C – Coordination of Benefits
You must submit claims within one year of date of purchase or as required by your plan.
When submitting an Explanation of Benefits (EOB) from another Health Plan or Medicare: If you have not already done so,
submit the claim to the Primary Plan or Medicare. Once you receive the EOB, complete this form, submit the pharmacy receipts, and
attach the EOB. The EOB must clearly indicate the cost of the prescription and amount paid by the Primary Plan or Medicare.
When submitting a copay receipt: If your Primary Plan requires you to pay a copayment or coinsurance to the pharmacy, then
no EOB is needed. Just complete this form and submit the pharmacy receipts showing the amount you paid at the pharmacy. These
receipts will serve as the EOB.
VALID 11 digit NDC# Quantity*
Compounding Fee
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The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in
health programs and activities.
Free services are provided to help you communicate with us, such as letters in other languages or large
print. You may also ask to speak with an interpreter. To ask for help, please call the toll-free phone number
listed on your ID card.
ATENCIÓN: Si habla español (Spanish), La compañía no discrimina por raza, color, nacionalidad, sexo,
edad o discapacidad en actividades y programas de salud.
Se brindan servicios gratuitos para ayudarle a comunicarse con nosotros, como cartas en otros idiomas
o en letra grande. También puede solicitar comunicarse con un intérprete. Para solicitar ayuda, llame al
número de teléfono gratuito que gura en su tarjeta de identicación.