Pharmacy Provider Relations Intake Form

Use this form to submit network rejections, pricing inquiries, and claim payment issues to Pharmacy Provider Relations


ORx PPR Intake Form V3.3

  • You must review the attached INSTRUCTION TABLE for Intake Form Guidelines.
  • If you require assistance with filling out the Intake form, you may request a meeting so that our team can do an overview.
  • For additional questions or to set up a meeting, contact our team at provider.relations@optum.com.

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ORx PPR Instruction videos on how to fill out the Pharmacy Provider Relations Intake Form