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OptumRx Mail Order
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OptumRx Mail Order

To order through OPTUMRx, please download the forms, then fill out all required information before submitting them via mail or fax.


Mail-In Form

Fax Form

  • Member Information
    • Special Medical Reimbursement Program
    • FSA Management
    • HRA Management
    • Debit Card Program
    • Dental Plan Administration
    • FAQs
  • Downloadable Forms
  • Employer
    • COBRA Event
    • Enrollment or Termination
    • Medicare Part D Forms
  • Member
    • Clinical Medical Release
    • FSA Dependent Care Reimbursement
    • FSA Healthcare Reimbursement
    • HRA Reimbursement Form
    • HRA Rx Reimbursement Form
    • HIPAA Forms
    • Medical Information Release
    • OptumRx Mail Order
    • Prescription Reimbursement
    • Prior Authorization
    • Quantity Limit Medical Necessity PPI
    • Quantity Limit Medical Necessity Request
    • Step Therapy Medical Necessity
    • Walgreens Mail Order Registration
    • Walgreens Mail Order Physician Fax
    • Formulary
  • Pharmacy
    • MAC List Appeal Form
    • TN Standard Pharmacy Reimbursement Form for Actual Cost Appeals

Resources

OptumRx Mail Order

To order through OPTUMRx, please download the forms, then fill out all required information before submitting them via mail or fax.


Mail-In Form

Fax Form

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