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Download and print the prior authorization request form for Optum Rx, a pharmacy benefit manager. The form requires member and provider information, medication information, clinical information, and quantity limit requests.
A PDF form for providers to request coverage for medications that require prior authorization from UnitedHealthcare. The form includes member, provider, medication and clinical information, and requires prescriber attestation and signature.
The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior authorization (PA) guidelines* to encompass assessment of drug indications, set guideline types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective dates and more.
Optum Rx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations. Visit go.covermymeds.com/OptumRx to begin using this free service. Please note: All information below is required to process this request. Mon-Fri: 5am to 10pm Pacific / Sat: 6am to 3pm Pacific .
Learn what prior authorization (PA) is, how to find out if your medication needs it, and how to submit a PA request. This PDF guide from Optum Rx explains the PA process, timeline, and coverage options for your pharmacy benefit.
Learn how to submit prior authorization requests to OptumRx electronically through CoverMyMeds or Surescripts portals. Find guidelines, procedures, and resources for ePA and other options.
Refill and manage your prescriptions online, anytime. Find low RX prices. Fast, free delivery to your home or office with OptumRx drugstore.
Find out which medications require prior authorization and how to request it. Download the PDF form for your benefit plan and review the medication list by therapy class.
OptumRx is an Optum® company – an independent company that provides home delivery, specialty, and infusion pharmacy services. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.
Download and print the prior authorization form for general/non-preferred drugs for TennCare members. The form requires member and prescriber information, requested drug information, clinical criteria documentation, and prescriber signature.