How it works.
1
Order up to a three-month supply of your maintenance
medications — ones you take regularly — by mail, phone or online.
2
OptumRx
®
fills your order, mails it to you and lets you know
when to expect your delivery.
3
Your medication arrives within 7 to 10 days of placing the order.
OptumRx will notify you if there will be a delay in your order.
Four easy ways to enroll:
Online.
Log in to the website on the back of your member ID card.
Phone.
Call the toll-free number on the back of your member ID card.
Mail.
Complete the attached order form and mail it to
OptumRx, P.O. Box 2975, Mission, KS 66201.
ePrescribe.
Or your doctor can send an electronic prescription to OptumRx.
Manage your medication home delivery on the go.
Order and track your prescriptions online or with our app.
Fill your prescriptions with home delivery.
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health
products. We are an Optum
®
company — a leading provider of integrated health services. Learn more at optum.com.
All Optum
®
trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks
or registered marks of their respective owners.
© 2016 Optum, Inc. All rights reserved. ORX9542_160602
The benefits of
home delivery.
Your medication
is delivered right
to your mailbox,
saving you a trip
to the pharmacy.
Your maintenance
medication could
cost less.
Pay nothing
for standard
shipping.
Phone, text
1
and email
reminders help
you remember
every dose and
every refill.
1
OptumRx provides this service at no additional
cost. Standard message and data rates charged
by your carrier may apply.
NRX001
NEW PRESCRIPTION MAIL-IN ORDER FORM
Member and physician information — please use black or blue ink. One form per member.
Member ID Number
(Additional coverage, if applicable) Secondary Member ID Number
Last Name First Name
MI
Delivery Address
Apt. #
City State ZIP
Phone Number with Area Code
Date of Birth (mm/dd/yyyy) Gender
M F
Email
Physician Name
Physician Phone Number with Area Code
Health history
Medication Allergies:
Aspirin
Erythromycin
Quinolones
Others:
None known
Cephalosporins
NSAIDs
Sulfa
Amoxil/Ampicillin
Codeine
Penicillin
Tetracyclines
Health Conditions:
Asthma
Glaucoma
High cholesterol
Others:
None known
Cancer
Heart condition
Osteoporosis
Arthritis
Diabetes
High blood pressure
Thyroid Disease
Over-the-counter/herbal medications taken regularly:
Payment and shipping information — do not send cash
Standard delivery is included at no charge. New prescriptions should arrive within about 10 business days from the date the completed
order is received. Completed refill orders should arrive within about 7 business days. OptumRx will contact you if there will be an
extended delay in delivering your medications.
For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such expenses
related to prescription orders. By supplying my credit card number, I authorize OptumRx to maintain my credit card on file as
payment method for any future charges. To modify payment selection, contact customer service at any time.
1
2
3
4
You may log on to optumrx.com to see if drug pricing information is available before enclosing payment. Once shipped, medications
may not be returned for a refund or adjustment.
Mail
this completed order form with your new prescription(s) to OptumRx, P.O. Box 2975,
Mission, KS 66201. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.
54777-032016
ORX5633_140915
Ship overnight. Add $12.50 to
order amount (subject to change).
Check enclosed. All checks must be
signed and made payable to: OptumRx.
Charge to my credit card on file.
Charge to my NEW credit card.
Signature:
Date:
New Credit Card Number
Expiration Date (Month/Year)
Visa, MasterCard, AMEX
and Discover are accepted.
