Prescription Reimbursement Request Form - Optumrx Page 2
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1
2Instructions 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, P.O. Box 29044, 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 – 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
Quantity
Prescribing physician name or ID number
Section B – Pharmacy Information
(for compound prescriptions ONLY)
(Pharmacist must complete and sign)
Date
Days
Rx#
• List VALID 11 digit NDC number (highest to lowest
Filled
Supply
cost) in the box at right. Include EACH ingredient
used in the compound prescription.
Ingredient
VALID 11 digit NDC#
Quantity*
Cost
†
• 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.
Compounding Fee
X
Signature of Pharmacist
Total
Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submits a claim or application
containing any materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing
a fraudulent insurance act which is a crime and may subject such person to criminal or civil penalties, including fines and/or
imprisonment, or denial of benefits. *
* Arizona: For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly
presents a false or fraudulent claim for payment or a loss is subject to criminal and civil penalties.
* California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents
false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
ORX5262B_130518
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