HD Form

main-form-root-panel
hd-footer

Welcome to Optum Home Delivery Pharmacy

What to expect

Avoid long lines and limited hours at the pharmacy and get your prescriptions delivered directly to your door with Optum® Home Delivery Pharmacy. Before we get your account set up and your prescriptions transferred, we’ll need some information. Please note that if you close out of the form before completion, you’ll have to restart from the beginning. The information you provide in this form allows us to better meet your medical needs and get your prescriptions transferred in a timely manner.

Personal/health information

Once you continue, you’ll be asked to enter your personal details and contact information. You’ll also be asked to provide details about your medication allergies, current or previous health conditions, and any over-the-counter medications or supplements you may be taking.

Prescription information

You’ll be prompted to enter the information for your prescriptions you’d like to transfer to Optum Home Delivery Pharmacy, including the details of the corresponding pharmacy and prescriber. After your plan is effective, we will contact your prescriber or pharmacy to get your prescriptions so we can process them for your requested delivery dates.

New to Optum?

If you’re a new member, please have your plan information available. You’ll need to provide your plan effective date.

Please select an answer to continue

No, I have an active plan

I’m an existing member signing up for home delivery.

Yes, I am a new member

I’m a new member signing up for home delivery.

Review

Account creation

You have :no_of_invalid_fields field(s) that need to be corrected:

Plan-effective date

To get started, select your plan’s effective date from the drop-down menu below. In most cases, your plan-effective date is the 1st day of the month your coverage begins. By providing this information, you will be able to set a home delivery date. You can begin scheduling home delivery two weeks after your plan is active.

Fields marked with an asterisk * are required.

Plan-effective date

Number of Plan-effective dates

Patient information

Please enter your personal information below.

Fields marked with an asterisk * are required.

First name

Middle initial

Last name

Gender

Date of birth

mm/dd/yyyy

Street address

City

State

ZIP code

Contact information

Please enter your contact information below.

Fields marked with an asterisk * are required.

Phone number

xxx-xxx-xxxx

Email address

name@email.com

Confirm email address

name@email.com

Form summary

Please review the information you’ve provided below before submitting your enrollment. You can click on any of the cards below to edit your information.

Account information

The patient and contact information you provided are listed below.

Patient information

Contact information

Edit account information

Edit plan-effective date

Plan-effective date

Edit personal information

Fields marked with an asterisk * are required.

First name

Last name

Date of birth

mm/dd/yyyy

Gender

Edit shipping address

Fields marked with an asterisk * are required.

Street address

City

State

ZIP code

Edit contact information

Fields marked with an asterisk * are required.

Phone number

xxx-xxx-xxxx

Email address

name@email.com

Confirm email address

name@email.com

Health information

You have :no_of_invalid_fields field(s) that need to be corrected:

Health information

Your medication allergies, health conditions, and supplements/over-the-counter medications are listed below.

Medication allergies

If you have current allergies to any particular medication, please list them below.

Fields marked with an asterisk * are required.

Do you have any current allergies?

Yes

Edit medication allergies

Use the field below to enter any medication allergies you have.

Search to add your medication allergies using the field below.

Add medication allergies

Medication allergies to be added

Medication Allergies

Health conditions

If you have any current or previously active health conditions, please list them below.

Fields marked with an asterisk * are required.

Do you have any current or previous health conditions?

Yes

Edit health conditions

Use the field below to enter any current or previous health conditions you may have or have had.

Search to add your health conditions using the field below.

Add health conditions

Health conditions to be added

Health Conditions

Supplements/Over-the-counter medications

If you’re currently taking any health supplements or over-the-counter medications, please list them below.

Fields marked with an asterisk * are required.

Are you currently taking any supplements or over-the-counter medications?

Yes

Edit supplements

Use the field below to enter any health supplements or over-the-counter medications you’re currently taking.

Add your supplements or over-the-counter medications using the field below.

Add supplements or over-the-counter medications

Supplement to be added

Supplements/OTC

Prescription information

Please add at least one prescription to continue.

Prescriptions

Prescription information

The prescriptions you’d like to transfer to Optum® Home Delivery Pharmacy are listed below.

Use the field below to add details for any prescriptions you’d like to transfer to Optum® Home Delivery Pharmacy.

The delivery date you requested for one or more of your prescriptions is no longer valid. Please update your requested delivery date to complete your enrollment.

The delivery date you requested for one or more of your prescriptions is no longer valid. Please update your requested delivery date to continue your enrollment.

Please update requested delivery date

Invalid Delivery Date Message

Add new prescription

Please have your prescriber and pharmacy information available.

You’ve reached the maximum number of prescriptions that can be added for a prescriber

Edit prescription information

Add prescription information

Use the fields below to edit the information for the prescription you’d like to transfer to Optum Home Delivery Pharmacy.

Use the form below to enter the details of the prescription you’d like to transfer to Optum® Home Delivery Pharmacy.

Fields marked with an asterisk * are required.

Medication name

Request Delivery Date Tooltip text for New Member

Manage prescribers

Prescriber information

Use the form below to add information for the prescriber who prescribed you this medication.

Use the fields below to edit the information for the prescriber who prescribed you the medication you’d like to transfer to Optum Home Delivery Pharmacy.

Edit your existing prescriber information or add a new prescriber.

Manage prescribers

Make updates or add new prescribers

Add prescribers

Please have their phone number available.

Please add a prescriber for this prescription

You’ve reached the maximum number of prescribers that can be added

Manage pharmacies

Pharmacy information

Use the form below to add the information for the pharmacy from which you’re transferring this prescription.

Use the fields below to edit the information for the pharmacy from which you’d like to transfer a prescription to Optum Home Delivery Pharmacy.

Edit your pharmacy information or add a new pharmacy below.

Manage pharmacies

Make updates or add new pharmacies

Add pharmacies

Select the current pharmacy you’re using for this prescription.

Please enter a pharmacy for this prescription

You’ve reached the maximum number of pharmacies that can be added

Delete prescription

If you delete this prescription, we’ll retain your prescriber and pharmacy details to be used with other prescriptions.

Delete prescription

If you delete your medication, it will no longer be saved to your enrollment form.

Edit prescriber

Add prescriber

Use the form below to add details for your prescriber for this medication.

Use the fields below to edit the information for the prescriber who prescribed you the prescription you’d like to transfer to Optum Home Delivery Pharmacy.

Fields marked with an asterisk * are required.

First name

Last name

Prescriber phone number

Street address

City

State

ZIP code

Edit pharmacy

Add pharmacy

Use the form below to add the information for the pharmacy from which you’re transferring this prescription.

Use the fields below to edit the information for the pharmacy from which you’d like to transfer a prescription to Optum Home Delivery Pharmacy.

Fields marked with an asterisk * are required.

Pharmacy name

Pharmacy phone number

Pharmacy address

City

State

ZIP code

Delete prescription

Please confirm that you want to remove [med name] from your prescriptions. We’ll retain your prescriber and pharmacy details so you can use them with other prescriptions.

Other information and next steps

Order will start processing on your plan effective date. We will contact your doctor for a new prescription. If we are unable to obtain your prescription from your doctor, we will reach out to your pharmacy to transfer your prescription. We will keep you informed via email on the progress of your order. Please continue to fill your current prescription and ensure you have enough medication to last through your requested delivery date to avoid any lapses in your drug therapy.

Once your order is processed, and only on or after your plan effective date, visit us online at the website listed on the back of your member ID card to track the status of your order and use other helpful tools.

Standard delivery is included at no charge. The pharmacy will contact you if there is a delay in delivering your medications.

By law, Optum pharmacies cannot accept returns of prescription products for reuse or resale. Accordingly, Optum Home Delivery does not offer credits or refunds for returned medications or supplies that were properly dispensed. If you think that there was an error in filling your prescription, or you have any questions about your order, please contact us.

Optum Home Delivery Pharmacy

The text will appear here

Form field 1

Form field 2

Form field 1

Form field 2

Form field 1

Form field 2

Form field 1

Form field 2

Form field 1

Form field 2

Congratulations, your enrollment request has been submitted.

Your enrollment information is listed below. Enrollment will only become active on your plan’s enrollment date, at which point your prescription orders will be processed per your requested fill dates. Please download or print this page for your records.

Other information and next steps

Standard delivery is included at no charge. The pharmacy will contact you if there is a delay in delivering your medications.

Confirmation Page Configurations

Account information

Personal Information Title

Personal Information Plan-effective date Title

Personal Information Name Title

Personal Information Address Title

Personal Information Phone Title

Personal Information Email Title

Personal Information Gender Title

Personal Information Date of birth Title

Personal Information MBI Title

Health information

Health information Title

Health information Allergies Title

Health information Conditions Title

Health information Supplements or over-the-counter medications Title

Prescription Information

Prescription Information Title

Prescription Information Prescription Title

Prescription Information Name Title

Prescription Information Fill date Title

Prescription Information Prescriber Title

Prescription Information Pharmacy Title

Prescriber Information

Prescriber Information Title

Prescriber Information Prescriber Title

Prescriber Information Name Title

Prescriber Information Phone number Title

Prescriber Information Address Title

Pharmacy Information

Pharmacy Information Title

Pharmacy Information Pharmacy Title

Pharmacy Information Name Title

Pharmacy Information Phone number Title

Pharmacy Information Address Title

Account Creation Title in Wizard

Health info Title in Wizard

Prescriptions Title in Wizard

Review Title in Wizard

Account Creation css selector

Health info css selector

Prescriptions css selector

Review css selector

Success Toast Text

Failure Toast Text

Maximum number of pharmacies allowed

Maximum number of prescribers allowed

Maximum number of prescriptions allowed per prescriber

Maximum number of health information fields