Optumrx direct member reimbursement form 2025

1. Click ‘Get Form’ to open the optumrx direct member reimbursement form in the editor.
2. Begin by filling out the Patient Information section. Provide your Health Plan/Insurance Name, Group Employer/Name, and your personal details including Last Name, First Name, Middle Initial, I.D. Number, Mailing Address, Birth Date, Prescribing Physician's Name, and their Telephone Number.
3. In the Reason For Request field, clearly state why you are seeking reimbursement for your prescription drug purchase.
4. If applicable, complete the Coordination of Benefits section by providing details about your primary insurance that has already paid for the prescription. Include an Explanation of Benefit from them.
5. For compound prescriptions, ensure that a pharmacist completes and signs this section. List each ingredient's VALID 11 digit NDC number along with its corresponding metric quantity.
6. Indicate the total charge paid by you for the prescription and attach all necessary receipts as proof of purchase.
7. Finally, sign and date the form at the bottom to certify that all information is accurate before submitting it to Prescription Solutions by OptumRx.

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