If you would like to submit a paper claim for reimbursement for a prescription that you paid for out of pocket, please print a copy of the Generic Reimbursement Claim Form located below.
After filling out the necessary information, please read the acknowledgement carefully (located at the bottom of page) and sign and date in the space provided.
To submit a Generic Reimbursement Claim Form, please be sure your receipts are complete. In order for your request to be processed, all receipts must contain the information listed below:
- Date prescription filled
- Name and address of pharmacy
- Doctor name or ID number
- NDC number (drug number)
- Name of drug and strength
- Quantity and days’ supply
- Prescription number (Rx number)
- DAW (Dispense As Written)
- Amount paid
This information can usually be found on the receipt which is stapled on the outside of the packaging or in some cases located inside. Your pharmacist can provide the necessary information as well.
Please mail completed form and receipt(s) to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
If you would like to submit a paper claim for reimbursement for a prescription that you paid for out of pocket, please print a copy of the Generic Reimbursement Claim Form located below.
After filling out the necessary information, please read the acknowledgement carefully (located at the bottom of page) and sign and date in the space provided.
To submit a Generic Reimbursement Claim Form, please be sure your receipts are complete. In order for your request to be processed, all receipts must contain the information listed below:
- Date prescription filled
- Name and address of pharmacy
- Doctor name or ID number
- NDC number (drug number)
- Name of drug and strength
- Quantity and days’ supply
- Prescription number (Rx number)
- DAW (Dispense As Written)
- Amount paid
This information can usually be found on the receipt which is stapled on the outside of the packaging or in some cases located inside. Your pharmacist can provide the necessary information as well.
Please mail completed form and receipt(s) to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
If you would like to submit a paper claim for reimbursement for a prescription that you paid for out of pocket, please print a copy of the Generic Reimbursement Claim Form located below.
After filling out the necessary information, please read the acknowledgement carefully (located at the bottom of page) and sign and date in the space provided.
To submit a Generic Reimbursement Claim Form, please be sure your receipts are complete. In order for your request to be processed, all receipts must contain the information listed below:
- Date prescription filled
- Name and address of pharmacy
- Doctor name or ID number
- NDC number (drug number)
- Name of drug and strength
- Quantity and days’ supply
- Prescription number (Rx number)
- DAW (Dispense As Written)
- Amount paid
This information can usually be found on the receipt which is stapled on the outside of the packaging or in some cases located inside. Your pharmacist can provide the necessary information as well.
Please mail completed form and receipt(s) to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
