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
RxGroup (see ID card) Member ID (see ID card)
Last Name First Name MI
Mailing Street Address Apt. #
City State ZIP
Prescription is for Self Spouse Dependent Gender M F Date of Birth (mm/dd/yyyy)
Custodial parent information
For reimbursement requests from a parent for a child (under the age of 18) when the requesting parent meets both of the following requirements:
1. Parent is not enrolled in the same Group Health plan as the child
2. Parent does not reside in the same household as the subscriber under the child’s Group Health plan
If your child is covered under two or more health plans, state law determines the order of benefits for processing claims.
Legal custodian’s name Legal custodian’s contact phone
Custodian requesting reimbursement name Custodian requesting reimbursement contact phone
Address payment is to be mailed to
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 (please explain)
 I filled a compound prescription (your pharmacist must
complete section B on the back of this form)
 I purchased medication outside of the United States
Country
Currency used
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
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
Other (please explain)
Acknowledgement
I certify that the medication(s) for which reimbursement is requested were received for use by the patient above, and that I
(or the patient, if not myself) am eligible for prescription drug benefits. I also certify that the medicationsreceived were not for
treatment of an on-the-job injury. I recognize reimbursement will be paid directly to me and assignment of these benefits to a
pharmacy or any other party is void.
X
Signature Date
1
2
3
4
5
PRESCRIPTION REIMBURSEMENT REQUEST FORM
ORX5262E_190226
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 5) 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)
• 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.
X
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.
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.
Rx#
Date
Filled
Days
Supply
VALID 11 digit NDC# Quantity*
Ingredient
Cost
†
Compounding Fee
Total
ORX5262E_190226 61908-022019
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.
請注意：如果您說中文 (Chinese)，公司不会基于种族、肤色、国籍、性别、年龄或残疾而在健
康计划和活动中歧视任何人。
为帮助您与我们沟通，我们提供一些免费服务，例如用其他语言书写的信件或大字体。您也可以
要求与口译员对话。欲寻求帮助，请拨打您的 ID 卡上列出的免费电话号码。