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Claim reimbursement form

Loading claim reimbursement form...

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Claim reimbursement, made easy.

Please review below our description of the claims reimbursement process and note the information you’ll need available. Unfortunately, we can only process one prescription per claims reimbursement submission at this time.

As easy as 1, 2, 3...

Our claims reimbursement process is quick, simple and just requires you to enter some basic information about your claim and prescription.

Enter patient information

Upload and enter claims information

Provide mailing address and signature

Materials needed

Be sure to have the following materials and information on hand as you’ll need it to fill out the claim reimbursement form.

Pharmacy receipt(s)

To submit your claims reimbursement request, you’ll need to upload your pharmacy receipt as proof of purchase for your prescription. Your pharmacy receipt (not to be confused with your store or register receipt) is typically attached to or included with your medication, or it can be obtained by contacting your pharmacy or via their website or app. Please attach documentation or images of your receipt in an upright, vertical orientation. A clear and unobstructed image is critical; please avoid any shadows, reflections, or obstructions that could impede readability. If you do not have the means to upload a pharmacy receipt, please consider submitting by mail.

Prescription details

Before submitting your request for claim reimbursement, you’ll need to have your prescription details available, which include the dose, Rx number, NDC (national drug code), and prescription fill date, all of which should be located on your pharmacy receipt.

Prescriber and pharmacy information

You’ll also need to confirm the prescriber for your prescription(s), and enter in their name and location, as well as the name and location of the pharmacy corresponding to your prescription.

Mailing address and patient information

If your claims reimbursement request is accepted, we’ll send you a check by mail to your provided mailing address. Please be ready to provide your preferred mailing address and contact information.

Claim reimbursement form

Claim reimbursement, made easy.

Patient information

Filing for yourself, household members, or care recipients

If filing on behalf of yourself or a care recipient or household member on your Optum Rx account, sign in using the link at the bottom of this page. Once signed in, you’ll be given an option to select whom you’re filing this claim for.

Filing on behalf of a patient

If you are filing for reimbursement on behalf of a patient, please have at least one of the following documents ready to upload to verify your representation, or use the forms provided below:

CMS-1696 form
Power of Attorney (POA) form
Guardianship papers

Court order
Executor of estate documentation forms
Health care proxy document(s)

Upload and enter claim information

Pharmacy receipt

First, you’ll need to upload your pharmacy receipt as proof of purchase for your prescription. Your pharmacy receipt (not to be confused with your store receipt) is typically attached to your medication, or it can be obtained by contacting your pharmacy or via their website or app. Please attach images of your receipt in an upright, vertical orientation. A clear and unobstructed image is critical; please avoid any shadows, reflections, or obstructions that could impede readability. If you do not have the means to upload a pharmacy receipt, please consider submitting by mail.

Prescription details

Prescriber and pharmacy information

You’ll also need to confirm the prescriber for your prescription(s), and enter in their name and location, as well as the name and location of the pharmacy corresponding to your prescription.

Provide mailing address and signature

Filing for yourself, household members, or care recipients

If your claims reimbursement request is accepted, we’ll send you a check by mail to your provided mailing address. Please be ready to provide your preferred mailing address and contact information.

Filing on behalf of a patient

If you’re filing on behalf of a patient, please enter your patient’s mailing address. If the claims reimbursement request is accepted, we’ll send them a check by mail.

Who are you filing this claim for?

Myself

Myself, a household member, a dependent, or a care recipient

Please sign in using your HealthSafe ID to continue.

On behalf of a patient as a legal representative

On behalf of a patient as a legal representative or custodial guardian

Please have your proof of representation or guardianship on hand before you submit your claim.

On behalf of a patient that works for the state of Alabama

Please have your proof of representation or guardianship on hand. If you’re filing for yourself as an Alabama state worker, please sign in. using the button above.

Patient information

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Claim information

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Mailing address and signature

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Mailing address and signature

Submitting your request

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Enter a mailing address

Please choose the mailing address you’d like your claim reimbursement sent to, should it be accepted. If filing on behalf of a patient as a legal representative or custodial guardian, please enter the patient’s address.

Select a mailing address

Please choose the mailing address you’d like your claim reimbursement sent to, should it be accepted.

Your addresses

Please select a mailing address or enter in a new one

I don’t see the address I need listed here

Addresses added to this form will not be saved to your profile..

Add a new address

Fields marked with a red asterisk * are required.

You have [no_of_errors] field(s) that need to be corrected:

Street address

Apt, Ste, or unit number

ZIP code

City

State

Contact information

Please confirm or enter your email address and phone number below

Your email address

[email_address]

Your phone number

[phone_number]

Edit email address

Fields marked with an asterisk * are required.

Email address

Edit phone number

Fields marked with an asterisk * are required.

Phone number

Patient representative contact information

Please confirm or enter your email address and phone number below

Email and phone number

Fields marked with a red asterisk * are required.

You have [no_of_errors] field(s) that need to be corrected:

Email address

Phone number

Review and sign

Please review the terms and conditions and sign your name to continue

I acknowledge my request for reimbursement will be paid directly to me and any assignment of benefits to a pharmacy or any other party related to this claim is void. Parties agree entering my name electronically below shall have the same force and effect as an original signature.

Terms and conditions

Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submit a claims or application containing any materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance act which is a crime and may subject such person to criminal or civil penalties, including fines and/or imprisonment, or denial of benefits. I certify that the medication(s) for which reimbursement is requested were received for use by the member above, and that I (or the member, if not myself) am eligible for prescription drug benefits. I also certify that the medications received were not for treatment of an on-the-job injury.

Please enter your full name

Your claim has been successfully submitted

Confirmation number: [confirmation_number]

Checking your claim status

Once your claim has been uploaded, you can check the current status of your reimbursement on your Claims page. Please allow up to 4-6 weeks for your claim to be fully processed. You can also print or download this page using the link in the top right. The reimbursement check will be mailed to the policy holder. Reimbursement will be issued to the policy holder, not the dependents, even if an adult dependent requests the reimbursement. This applies unless there is a legal custody agreement or other specific financial arrangements in place that dictate otherwise.

If your claim is rejected, we will promptly send a detailed letter explaining the reasoning behind the rejection. You can also contact us and ask about your claim using your confirmation number. If you need further assistance, please feel free to contact us.

To check your claim status, please give us a call. Remember to have your confirmation number ready. Please allow up to 4-6 weeks for your claim to be fully processed. You can also print or download this page using the link in the top right.

Patient and mailing information

Patient representative

[legal_rep_name]

[legal_rep_email]

[legal_rep_phone]

[legal_rep_address]

Form submitter

[form_submitter_name]

[form_submitter_email]

[form_submitter_phone]

Patient name

[patient_name]

Mailing address for reimbursement

[address]

Claim information

Receipt or proof of purchase

[receipt_name]

Prescription information

Amount: $[amount]

Date: [date]

Rx #: [rx_number]

[daw_desc] (DAW [daw_code])

Medication information

[prescription_name]

Quantity: [no_of_dose]

Prescriber and pharmacy

[prescriber_name]

[pharmacy_name]

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