Prescription Reimbursement Forms

There may be times when you have to pay for your prescription out of pocket. Here, you’ll find the forms needed to get a refund from Physicians Health Choice.

If you have to purchase your prescription at a non-contracted pharmacy or at a pharmacy that will not accept your Physicians Health Choice ID card, please fill out the Prescription Reimbursement Form. Be sure to include the receipt of proof of purchase and mail to the Physicians Health Choice Pharmacy Benefit Manager (Prescription Solutions® by OptumRx™) at the address listed on the form.

The documents on our website are presented in PDF format. Click Here to install Adobe Acrobat.