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.

1

Enter patient information

2

Upload and enter claims information

3

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.

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.

1

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.

OR

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)

2

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

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. 

3

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

Please sign in using your HealthSafe ID to continue.

On behalf of a patient

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

Patient information

Tell us about your claim

Please let us know the patient you are filing this claim for and for what reasons you are requesting reimbursement.

Please let us know for what reasons you are requesting reimbursement.

Who are you requesting claim reimbursement for?

Please choose whom you are filing this claim for

I’m requesting a claim reimbursement for myself.
I’m requesting claim reimbursement for a care recipient of mine or someone in my household.

Which care recipient or household member?

Unable to load care recipients or household members

We’re sorry about the inconvenience. Please try again. If you continue to experience issues, come back in 30 minutes. 

Please select whom you are filing this claims reimbursement for

Why are you requesting reimbursement?

Tell us about your patient’s claim

Please let us know the patient you are filing this claim for and for what reasons you are requesting reimbursement.

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

Patient information

Fields marked with an asterisk * are required.

Your information

Fields marked with an asterisk * are required.

Your proof of patient representation

(e.g. At least one of the following documents: CMS-1696, POA, guardianship papers, court orders, or health care proxy)

file
Drag and drop your file here or
Accepted file formats include .pdf, .jpg, and .png (up to 50 MB in size)

    Unable to upload document

    We’re sorry about the inconvenience. Please check the file type and try uploading again or upload a different document.

    Your address

    Fields marked with an asterisk * are required. Please do not enter the patient’s address here.

    Why are you requesting reimbursement for this patient?

    Why are you requesting reimbursement?

    Please enter in your reason(s) for requesting claims reimbursement

    Compounded prescriptions

    Please read the explanation and confirm you understand by checking the box below

    When submitting a claim for compounded medications, please note that only one drug or product ingredient can be entered. For compounded medications, use your pharmacy receipt to identify the most frequently used or most expensive ingredient in the mixture and enter its details. Your pharmacy receipt should list the ingredient’s amounts (in mg, ml, etc.) and/or the price for each ingredient. 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. If your pharmacy receipt does not include the price or amount of each ingredient, please contact your pharmacy to obtain this information. When prompted for the total cost, please use the cost of your entire compounded medication, not just your selected ingredient.

    Loading claim reimbursement form...

    Claim information

    Pharmacy receipt

    Please upload at least one receipt or proof of purchase to continue

    Please upload your pharmacy receipt as proof of purchase for your claim reimbursement. You must upload a file before continuing with the form.

    Unable to submit document

    Your receipt must clearly list prescription, prescriber and pharmacy information, as well as your claim amount. Please confirm your image is high-resolution and includes the required information or enter in the information manually.

    Unable to upload document

    We’re sorry about the inconvenience. Please check the file type and try uploading again or upload a different document.

    file
    Drag and drop your file here or
    Accepted file formats include .pdf, .jpg, and .png (up to 5 MB in size)

      Prescription information

      Please enter your claim amount and prescription information as well as the corresponding prescriber and pharmacy information.

      We couldn’t find some of your prescription information. Please review the remaining fields below.

      Please save your claim information before continuing or your information will be lost

      Claim and prescription information

      Fields marked with an asterisk * are required.

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

      Please enter the date on which this prescription was filled. Fill date must be within the last 3 years.

      For over-the-counter medications, enter 123456789
      11-digit number

      You can find the NDC of your prescription near the drug name on your bottle or package, or on your pharmacy receipt. Leave the field blank if it's an over-the-counter medication, a foreign claim, or the NDC is unknown.

      How to find your NDC

      The National Drug Code or NDC is a unique 11-digit, 3 segment identifier for your medication. You can find the NDC of your prescription near the drug name on your prescription bottle or package.

      Please select the situation which best applies to this claim below. (This will be your DAW code number)

      Claim and prescription information

      Amount: $[amount]

      Date: [date]

      Rx #: [rx_number]

      Verify claim information

      [daw_desc]

      Medication information

      Medication information

      [medication_name]

      Quantity: [quantity]

      [day_supply]-day supply

      Verify medication information

      Search for your medication

      Fields marked with an asterisk * are required.

      Finding your
medication...

      Ouch! We ran into an issue.

      We’re currently working to fix it – and there’s a good chance it’s already been fixed. Please try again.

       

      If you do continue to experience issues, please contact us.

      Add medication

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

      [medication_name]

      Fields marked with an asterisk * are required.

      Total amount of medication per package

      (e.g. 60 capsules, 2 injections, etc.)

      Number of doses you receive per refill

      (e.g. 30-day, 90-day)

      No results found

      for “[medication_name]”

      We couldn’t find that medication

      Please check the spelling of your medication name and try a new search. You can also add medication information manually if you’re unable to find it in our system. 

      Medication information

      Add medication

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

      Fields marked with an asterisk * are required.

      (e.g., tablet, capsule, aerosal, etc.)

      (e.g. 10 mg, 80 mL, 30 mcg, etc.)

      Total amount of medication per package

      (e.g. 60 capsules, 2 injections, etc.)