Indemnity Plan Forms. Prescription Drug Reimbursement Claim Form (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.) Prescription Drug Reimbursement Request Form (OptumRx) (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed ....