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File a Prescription Claim

File a Prescription Claim

 

Welcome to the File a Prescription Claim Center! We understand the hassles that come along with filing your claims, which is why we want to make this process as quick and painless for you as possible. Below you will find all the information you will need to file a prescription claim.

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 Reimbursement Claim Form located below.

After filling out the necessary information, please read the acknowledgement carefully (located at the bottom of page1) and sign and date in the space provided.

To submit a 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 if not.

Please mail completed form and receipt(s) to:

OptumRx Claims Department

P.O. Box 29044

Hot Springs, AR 71903