RxContract Request form - Optum 2026

1. Click ‘Get Form’ to open the RxContract Request form in the editor.
2. Begin by entering today’s date at the top of the form. This helps track when your request was submitted.
3. Select your provider type by checking one of the boxes: Chain, PSAO, or Independent. Then, fill in your Provider Legal Name and NCPDP Number.
4. Provide your NPI and select your Pharmacy Type from the options available, including Retail, Clinic, Outpatient Hospital, Mail, Specialty, Long Term Care, Hospice, or Other.
5. Fill in the Services Offered section by checking all applicable services such as Compounding or DME.
6. Complete your Pharmacy Address details including City, State, Zip Code, and contact information like Phone and Email.
7. Answer the additional questions regarding provider agreements with OptumRx and Catamaran. Provide brief descriptions as needed.
8. Indicate whether your pharmacy dispenses medications to Medicare and Medicaid beneficiaries by checking Yes or No where applicable.
9. In the Claim Information section (if applicable), provide BIN, Date of Service, and Prescription Number if you have them.
10. Finally, complete the Signature Information section with names and titles of authorized individuals before submitting via phone, fax or email as indicated at the bottom of the form.

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