Fillable OptumRx Home Delivery Form Try Home Delivery From OptumRx

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OptumRx Home Delivery Form Try Home Delivery From OptumRx

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Try home delivery from OptumRx.
With OptumRx®, your copay could be as low as
$0
1
for many medications.
1
$0 copay may be restricted to particular tiers, preferred medications, or home delivery prescriptions
during the initial coverage phase and may not apply during the coverage gap or catastrophic stage.
How it works.
1
Order up to a 3-month supply of your maintenance
medications — ones you take regularly — from OptumRx.
2
OptumRx fills your order, and sends it to you.
3
Your medication arrives within 4 to 7 days.
The benefits of home delivery.
Save a trip to the pharmacy.
Talk to a pharmacist when you
have medication questions.
Set up medication reminders.
Four easy ways to set up home delivery:
ePrescribe. Ask your doctor to send an
electronic prescription to OptumRx.
Online. Log in to optumrx.com and follow the instructions.
Phone. Call OptumRx anytime at 1-888-658-0539, TTY 711.
Customer
Service can help you get started.
Mail. Complete this order form and mail it to:
OptumRx, P.O. Box 2975, Mission, KS 66201.
This information is not a complete description of benefits. Contact the plan for more information. Limitations,
copayments and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change on
January 1 of each year.
You are not required to use OptumRx home delivery for a <90-/100->day day supply of your maintenance
medication. If you have not used OptumRx home delivery, you must approve the first prescription order sent
directly from your doctor to OptumRx before it can be filled. Refill orders should arrive in about four business
days and new prescriptions should arrive within seven business days from the date OptumRx® receives the
completed order. Contact OptumRx anytime at 1-888-658-0539, TTY 711.
Plans are insured or covered by a Medicare Advantage organization with a Medicare contract and/or a
Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with
Medicare.
UnitedHealthcare Insurance Company complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: Si habla español,
hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número que aparece en la parte
de atrás de su tarjeta de ID de miembro. 請注意：如果您說中文，我們免費為您提供語言協助服務。請撥打會
員卡背面的電話號碼。
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.
Administrative services provided by UnitedHealthcare Insurance Company, UnitedHealthcare Services, Inc.
or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company. OptumRx is an
affiliate of UnitedHealthcare Insurance Company.
OptumRx is a subsidiary of UnitedHealth Group. UnitedHealthcare and the dimensional U logo are
trademarks of UnitedHealth Group Incorporated. All other trademarks are the property of their respective
owners. ©
2018 United HealthCare Services, Inc. All rights reserved. 70692-112017
<CMS number>
NEW PRESCRIPTION MAIL-IN ORDER FORM
1
Member and physician information — please use black or blue ink. One form per member.
Member ID Number
(Additional coverage, if applicable) Secondary Member ID Number
Last Name First Name
MI
Delivery Address
Apt. #
City State ZIP
Phone Number with Area Code
Date of Birth (mm/dd/yyyy) Gender
M F
Email
Physician Name
Physician Phone Number with Area Code
2
Health history
Medication Allergies:
None known
Amoxil/Ampicillin
Aspirin
Cephalosporins
Codeine
Erythromycin
NSAIDs
Penicillin
Quinolones
Sulfa
Tetracyclines
Others:
Health Conditions:
None known
Arthritis
Asthma
Cancer
Diabetes
Glaucoma
Heart condition
High blood pressure
High cholesterol
Osteoporosis
Thyroid Disease
Others:
Over-the-counter/herbal medications taken regularly:
3
Payment and shipping information — do not send cash
Standard delivery is included at no charge. New prescriptions should arrive within about 10 business days from the date the completed
order is received. Completed refill orders should arrive within about 7 business days. OptumRx will contact you if there will be an
extended delay in delivering your medications.
You may log on to optumrx.com to see if drug pricing information is available before enclosing payment. Once shipped, medications
may not be returned for a refund or adjustment.
Ship overnight. Add $12.50 to
order amount (subject to change).
Check enclosed. All checks must be
signed and made payable to: OptumRx.
Charge to my credit card on file.
Charge to my NEW credit card.
New Credit Card Number
Expiration Date (Month/Year)
V
isa, MasterCard, AMEX
and Discover are accepted.
Signature:
Date:
For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such expenses
related to prescription orders. By supplying my credit card number, I authorize OptumRx to maintain my credit card on file as
payment method for any future charges. To modify payment selection, contact customer service at any time.
4
Mail
this completed order form with your new prescription(s) to OptumRx, P.O. Box 2975,
Mission, KS 66201. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.
ORX5633E_140915
NRX001
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OptumRx Home Delivery Form Try Home Delivery From OptumRx

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Completed 16 July 2020

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