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Prescription Reimbursement Request Form
Print page 2 of this form on the back of page 1. Send completed form with pharmacy receipt(s) to: OptumRx Claims Department, PO Box 650 , Dallas, TX 75265-.
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2023 800 788 7871 filling D.0 - teloparkis.wiki
19 minutes ago Drug Benefit Fund or no coverage. Your cost sharing applies to the prescription drug out- OptumRx Address: 3515 Harbor Boulevard Costa
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Member Reimbursement Pharmacy Form
Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement. Submit this form.
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