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Forms

If you need to submit a claim for a prescription drug or you order your medications by mail, find the forms you need here.

Prescription Reimbursement Request Form

Use the Prescription Reimbursement Claim Form to file claims for covered prescriptions for which you paid 100 percent, for covered prescriptions you received without showing your ID card, and for covered prescriptions you received from a non-participating pharmacy. 

Mail Service Pharmacy Program

Members should use the Mail Order Prescription Form to order up to a 90-day supply for most maintenance medications through OptumRx Home Delivery. Please Note: Not all of our members have mail service prescription drug benefits. Members should check their health plan details or ask their benefits coordinators to make sure they have mail service benefits.

Mail Order Prescription Form - English

Mail Order Prescription Form - Spanish