Crohn's/Ulcerative Colitis. As part of an ongoing effort to increase security, accuracy, and timeliness of PA Some medications must be reviewed because . Dermatology. Open PDF, opens in a new tab or window. Now you may print, download, or share the form. Use the Sign Tool to add and create your electronic signature to signNow the Prior Authorization Request Form Member . Exclusions may include cost reduction requests such as tiering exception, copay waiver, and tier cost sharing.To submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., HCR), please contact the OptumRx PA department through coverage determinations for most PA types and reasons. We know PA requests are complex. endstream 1.1 We use this form to obtain your written consent to disclose your protected health information to someone designated by you. **The ePA solution supports all forms of PA and formulary exception requests. For requests for buy and bill, please contact the patients medical benefit. Open the email you received with the documents that need signing. hbbd```b``:"@$"&&@${ "Y`. A list of tried and failed medication must be provided as a justification for the request alongside the diagnosis. If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. For urgent or expedited requests please call 1-800-711-4555. y?S} T Our PDF editor will let you fill out any form quickly. making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. endobj Our electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible. The following January 1, 2023 flyers are sent to members to outline the drugs affected by prior authorization, quantity limits, and step therapy based on benefit plan designs. 139 0 obj This info will allow those at OptumRX to determine whether or not partial or full coverage is feasible. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 15 0 R 16 0 R 17 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R 41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R 49 0 R 50 0 R 51 0 R 52 0 R 53 0 R 54 0 R 55 0 R 56 0 R 57 0 R 58 0 R 59 0 R 60 0 R 61 0 R 62 0 R 63 0 R 64 0 R 65 0 R 66 0 R 67 0 R 68 0 R 69 0 R 70 0 R 71 0 R 72 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> endobj But there are circumstances where there's misalignment between what is approved by the payer and what is actually . endobj The Provider named above is required to safeguard PHI by applicable law. OptumRx is not authorized to review requests for medications supplied by the physicians office. telephone or fax. endobj If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against . endstream endobj 343 0 obj <>/Metadata 15 0 R/Names 372 0 R/Pages 339 0 R/StructTreeRoot 33 0 R/Type/Catalog/ViewerPreferences 373 0 R>> endobj 344 0 obj <>/MediaBox[0 0 612 792]/Parent 339 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 345 0 obj <>stream 370 0 obj <>/Filter/FlateDecode/ID[<6A51065327B04A46813B4732261321B1>]/Index[342 73]/Info 341 0 R/Length 135/Prev 314608/Root 343 0 R/Size 415/Type/XRef/W[1 3 1]>>stream Access the providers' prior authorization form to seek approval to prescribe medications for your patients. Specialty drugs typically require a prior authorization. Press Done after you fill out the blank. ' @}\,@:uX AS ~ - 2016-09-16T07:22:50.000-05:00 Submitting prior authorizations via ePA (electronic prior authorization) is the fastest and most convenient method for submitting prior authorizations. 1 0 obj Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE. Step 2 The first required information is that of the member. protect patient safety, as well as ensure the best possible therapeutic outcomes. <> The information in this document is for the sole use of OptumRx. The American Medical Association (AMA) wants to help bring ePA awareness to physician practices. Open the doc and select the page that needs to be signed. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request <>stream OptumRX Prior Prescription Authorization Form. For forms to request prior authorization for drugs covered under the retail pharmacy benefit, please visit the OptumRx Healthcare Professionals Portal. Click the New Document option above, then drag and . 16 0 obj Search for the document you need to electronically sign on your device and upload it. startxref endobj If you cannot submit requests to the OptumRx PA department through ePA or telephone,click here. As an OptumRx provider, you know that certain medications require approval, or Other ways to submit a prior authorization, Having difficulties with ePA? Exclusions may include cost reduction requests such as tiering exception, copay waiver, and tier cost sharing.To submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., HCR), please contact the OptumRx PA department through types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective This request does not allow your designated person to make any of your treatment decisions or direct care decisions. You need to record the rights and responsibilities of the sides within the field. 752dc44aac14d1f9c79b428b5625173e746a1557 PAs help manage costs, control misuse, and See buprenorphine/naloxone tab prior authorization criteria Now you'll be able to print, download, or share the document. Enter in the date and, once the document has been printed off, sign the signature field. endobj OptumRx Prior Authorization Health care professionals website Prior authorization for prescribers Prior authorizations (PAs) help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. 385 0 obj OptumRx New Prescription Physician Fax Download - Medicaid Prior Authorization video, BNK.WIKI. Call 1-800-711-4555, 5 a.m. 10 p.m. PT, Monday-Friday and 6 a.m. 3 p.m. PT, Saturday. OptumRx Prior Authorization and Exception Request Procedures Submitting an electronic prior authorization (ePA) request to OptumRx ePA is a secure and easy method for submitting,managing, tracking PAs, step therapy and non-formulary exception requests. Start a Prior Authorization with CoverMyMeds > I have been using this service since last year and it simply gets better and better. Follow the instructions below to fill out Optumrx tier exception form online quickly and easily: Make these fast steps to modify the PDF Optumrx prior authorization form online free of charge: Sign up and log in to your account. Open PDF, opens in a new tab or window. <> Injectable Psychotropic - Optum. Use este formulario para dar su consentimiento para la divulgacin de la informacin de salud protegida tanto verbal como escrita, que incluye su perfil o registro de recetas, a la persona que usted haya designado en el formulario. uuid:57a4631a-2f5b-460a-a79e-d6d5b547b995 <>/Filter/FlateDecode/ID[]/Index[138 56]/Info 137 0 R/Length 102/Prev 122747/Root 139 0 R/Size 194/Type/XRef/W[1 3 1]>>stream endstream DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. Select the area you want to sign and click. Take advantage of the top and left-side panel tools to redact Optumrx prior authorization form pdf 2021. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization telephone or fax. [19 0 R 21 0 R 22 0 R 24 0 R 186 0 R 187 0 R 187 0 R 187 0 R 187 0 R 187 0 R 184 0 R 185 0 R 185 0 R 185 0 R 185 0 R 185 0 R 183 0 R 180 0 R 179 0 R 178 0 R 175 0 R 174 0 R 173 0 R 172 0 R 168 0 R 167 0 R 166 0 R 163 0 R 162 0 R 161 0 R 158 0 R 157 0 R 156 0 R 155 0 R 154 0 R 149 0 R 148 0 R 147 0 R 146 0 R 145 0 R 139 0 R 140 0 R 140 0 R 140 0 R 140 0 R 140 0 R 138 0 R 135 0 R 136 0 R 134 0 R 133 0 R 132 0 R 128 0 R 127 0 R 126 0 R 123 0 R 122 0 R 119 0 R 118 0 R 114 0 R 115 0 R 115 0 R 115 0 R 115 0 R 115 0 R 113 0 R 100 0 R 101 0 R 102 0 R 103 0 R 104 0 R 105 0 R 106 0 R 107 0 R 108 0 R 109 0 R 110 0 R 111 0 R 99 0 R 56 0 R 57 0 R 58 0 R 97 0 R 96 0 R 93 0 R 92 0 R 89 0 R 88 0 R 85 0 R 84 0 R 81 0 R 78 0 R 79 0 R 80 0 R 75 0 R 74 0 R 71 0 R 70 0 R 60 0 R 55 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 20 0 R 25 0 R 188 0 R 191 0 R 189 0 R 27 0 R 28 0 R 23 0 R] The American Medical Association (AMA) wants to help bring ePA awareness to physician practices. Install the signNow application on your iOS device. Miley, David T manner, please submit all information needed to make a decision. Over 2/3 of the PAs that we receive each year are now electronic. OptumRx Prior Authorization Health care professionals website Prior authorization for prescribers Prior authorizations (PAs) help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. Step 1 Begin by downloading the form in Adobe PDF and opening it up in the PDF reader of your choice. Formulario Estndar de Autorizacin para la Divulgacin de Informacin de Salud Protegida (PHI) (Espaol) If yes, answer the two accompanying questions. If the physician is supply the medication, check that this is the case. Please complete all pages to avoid a delay in our decision. ee` fd ", Arkansas Prior Authorization or Exception Request, Online Claim Form: UHG, Medicare, PDP, MAPD, Commercial, PPO, Union and Others, Claim Form Medicare Part D Frequently Asked Questions English, Claim Form Medicare Part D Frequently Asked Questions Spanish, Claim Form: UHG, Medicare, PDP, MAPD, Commercial, PPO, Union and Others. This form may be sent to us by mail or fax: Address: OptumRx . That's why we have a team of experts and a variety of help resources to make requests faster and easier. TheOptumRX Prior Authorization Request Formis a simple form to be filled out by the prescriber that requests that a certain treatment or medication be covered for a patient. Allow at least 24 hours for review. HWn8}WiIJAdu$,d(j[~V&nge^U9UV ^<. Top. Authorization form - English PDF Formulario Estndar de Autorizacin para la Divulgacin de Informacin de Salud Protegida (PHI) (Espaol) Usamos este formulario para obtener su consentimiento por escrito para divulgar su informacin de salud protegida (protected health information, PHI) a alguien que usted haya designado. Submitting an electronic prior authorization (ePA) request to OptumRx Submit a prior authorization; Utilization management changes, effective 01/01/23; DPL Main Nav Items . There are three variants; a typed, drawn or uploaded signature. endobj The best way to edit Optumrx tier exception form in PDF format online 9.5 Ease of Setup DocHub User Ratings on G2 9.0 Ease of Use DocHub User Ratings on G2 Handling paperwork with our comprehensive and intuitive PDF editor is straightforward. Submitting a PA request Did you know Over 2/3 of the PAs that we receive each year are now electronic. P.O. En el caso de los Representantes Personales que hayan sido legalmente designados, pueden llenar este formulario y adjuntar documentacin legal de respaldo, tales como un Poder que indique la autoridad total para tomar decisiones sobre la atencin de la salud, documentacin de la tutela, etc. <>/MediaBox[0 0 612 792]/Parent 136 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> Our site is the place to go if you want to edit and acquire this form. these guidelines may not apply. We recommend you speak with your patient regarding Microsoft Word 2010 8X R@, f`\iW sXXNe`pj! endstream endobj startxref OptumRx Prior Authorization Form is a great way to get the drugs you need. endobj O4 Footer Nav Items. Member Information Prescriber Information Member Name: Provider Name . 15 0 obj <>/MediaBox[0 0 612 792]/Parent 192 0 R/Resources<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 0/Tabs/W/Type/Page>> No phone trees. <> For Personal Representatives that have been legally appointed, the Personal Representative can complete this form and attach supporting legal documentation, such as a Power of Attorney that indicates full health care decision-making authority, guardianship documentation, etc. 13 0 obj endobj your Dashboard to submit your PA request. review decisions on sound clinical evidence and make a determination within the timeframe Optum Prior Authorization Criteria Specific Forms Injectable Psychotropic - Optum Open PDF Neuromuscular - Optum - Achalasia, Chronic Anal Fissure, Detrusor Overactivity, Spasticity, Bleopharospasm Open PDF Neuromuscular - Optum - Migraine, Cervical Dystonia, Overactive Bladder Open PDF RSV- Optum Open PDF 12 0 obj DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. hbbd```b``[A$;fGH."Y@${8 "Y&(H RKD2DH`vdowmybefbC>10120>8B ) <>/Font<>>>/Fields[293 0 R 301 0 R 294 0 R 302 0 R 303 0 R 295 0 R 304 0 R 296 0 R 305 0 R 297 0 R 298 0 R 299 0 R 306 0 R 300 0 R 307 0 R 308 0 R 309 0 R 310 0 R 311 0 R 312 0 R 317 0 R 318 0 R 319 0 R 320 0 R 321 0 R 322 0 R 323 0 R 324 0 R 325 0 R 330 0 R 331 0 R 334 0 R 335 0 R 336 0 R 8 0 R 314 0 R 315 0 R 326 0 R 327 0 R 329 0 R 328 0 R 332 0 R 333 0 R 313 0 R 373 0 R]>> In the two bottom windows, enter in the directions for use and whether or not it is a continuation of a current therapy. Prior Authorization Form Mavyret This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). Utilize a check mark to point the choice wherever required. 140 0 obj Verify your NPI to receive all requests initiated at your patients pharmacies, Use your account to initiate, access and submit requests, HIPAA compliant and available for all plans and all medications. Prior Authorization Request Form Author: Miley, David T Subject: OptumRx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations. x=i ?$u-)7^,fh${/dW{=N8h.b^=>^m>xsw}O'?iG_B4eUoZ=*l___. Optum Prior Authorization Criteria Specific Forms. 193 0 obj For more information on HIPAA individual rights, click here. It has significantly reduced the paperwork burden of my office and office staff as far as prior authorizations go. 2023 CoverMyMeds LLC. We offer other various resources to help support your understanding and use of ePA. These rights are collectively known as Individual Rights. Providers. prescription drug benefits may be covered under his/her plan-specific formulary for which Please note: All information below is required to process this request 192 0 obj Please review each document for more details. The information inthis document isfor the sole use of OptumRx. Optimal. Click here to view the OptumRx PA guidelines and Exception Request Procedures. Use this form in Arizona, Nevada and Utah. % Super Fast Download Medicaid Prior Authorization video HD Youtube HD. submitting pharmacy prior authorization requests for all plans managed by That's why we have a team of experts and a variety of help resources to make requests faster and easier. Specialty drugs and prior authorizations. Download now. . This form may be used for non-urgent requests and faxed to 1-800-527-0531. . Before doing so however, enter in any other comments, diagnoses, symptoms etc. Create your signature, and apply it to the page. Provider named above is required to safeguard PHI by applicable law. 2 - Express Scripts data on file, 2019. 1 - CoverMyMeds Provider Survey, 2019. <> Certain states require Optum Rx to communicate prior authorization changes before the effective date. Double check all the fillable fields to ensure complete accuracy. Create an account using your email or sign in via Google or Facebook. If you are new to electronic prior authorizations (ePA), here are a few benefits to consider: Saves time: Providers who report using ePA submissions on average spend 2.5 fewer hours on PAs per week*, Provides real-time submissions with typical resolutions in less than 5 minutes at no additional cost, Eliminates wait time on the phone or using manual fax forms, Reduces disruptions to patient care, Allows renewals to be created from previous submissions, Includes specific clinical questions pertinent to patient plan requirements, Reduces paperwork: Process is eco-friendly, Protects patient health information: Provides secure transmission using the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard, Save time today and submit your PA requests to OptumRx through any of the following online portals:**. Make adjustments to the template. Start a Request Scroll To Learn More Why CoverMyMeds <>>> allowed by state or federal law. If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. You can submit a verbal PA request. Optum Prior Authorization Criteria Specific Forms. Create this form in 5 minutes! This form may contain multiple pages. hb```g``fa`e`X}A@,3.Y600Ix^ ` Step 3: Click the Done button to save the file. Go to the Chrome Web Store and add the signNow extension to your browser. Lack of information may delay Utilization management updates . prescription drug benefit coverage under his/her health insurance plan or call OptumRx. If you cannot submit requests to the OptumRx PA department through ePA or telephone,click here. It enables a faster turnaround time of Patients. We strongly This will require the following: Step 4 The medications name, strength and dosage form must be enter next. OptumRx's Preferred Method for Prior Authorization Requests Our electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible. . If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. . OptumRx, except for the following states: MA, RI, SC, and TX. We offer other various resources to help support your understanding and use of ePA. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. hVn8>X$I"(8qhEnDX2$I~P-;v4pf4s52tL0 BLI`VL Y3(9d6sa$@9t!Xu! %PDF-1.5 endstream 2016-12-02T11:43:26.719-06:00 138 0 obj **The ePA solution supports all forms of PA and formulary exception requests. above. A Personal Representative may be legally appointed or designated by the member or patient to act on their behalf. 414 0 obj <>stream LET's GET STARTED. July 1, 2022. Enter their name, insurance ID number, DOB, full address, and phone number. Download Enrollment Forms. Step 6 Check the yes box to indicate that all the information provided is both true and accurate. <>stream Improving efficiencies without sacrificing the essentials, Three Easy steps to completing requests electronically. endobj Step 1 - Begin by downloading the form in Adobe PDF and opening it up in the PDF reader of your choice. OptumRx is not authorized to review requests for medications supplied by the physicians office. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior Formulario de autorizacin - PDF en espaol. (Hours: 5am PST to 10pm PST, Monday through Friday. The advanced tools of the editor will lead you through the editable PDF template. Enter their name, insurance ID number, DOB, full address, and phone number. %%EOF V3`#lK2m%\ekvNYN9(^,4b"wx?_y=X]>d''x7|{rO0slTZcL(A$9cOij&KM?|PW( ~?: ,5/V!}=#Y:w53~))$VS|4Bq")rUj7nN'7C|v C*rMFDMdb)y]E*DJc 05ZAk YyY_4NdEsAk^OI"@D_ 02 17 0 obj 196 0 obj 342 0 obj <> endobj Prior Prescription (RX) Authorization Forms, OptumRX Prior Prescription (Rx) Authorization Form, CVS Prior Prescription (Rx) Authorization Form, CIGNA Prior Prescription (Rx) Authorization Form, Future Scripts Prior Prescription (Rx) Authorization Form, Meridian Prior Prescription (Rx) Authorization Form, Amerigroup Prior Prescription (Rx) Authorization Form, EnvisionRX Prior Prescription (Rx) Authorization Form, Humana Prior Prescription (Rx) Authorization Form, Harvard Pilgrim Healthcare Prior Prescription (Rx) Authorization Form, Authorization Forms Adobe PDF and Microsoft Word. 1 Sign in to the editor with your credentials or click Create free account to evaluate the tool's features. Please contact the OptumRx Prior Authorization department at 1-800-711-4555 or . endobj To ensure that a PA determination is provided to you in a timely 14 0 obj Easily sign the optumrx prior authorization form 2022 with your finger. endobj Add the Optumrx prior authorization form for redacting. This form may be used for non-urgent requests and faxed to 1-800-527-0531. O4 Footer Nav. Over 2/3 of the PAs that we receive each year are now electronic. 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If the patient is not able to meet the above standard prior authorization requirements, please call 1-800 -711 -4555. Prior authorization form. We know PA requests are complex. OptumRx has partnered with CoverMyMeds to receive prior authorization requests, . ePA is a secure and easy method for submitting,managing, tracking PAs, step Microsoft Word 2010 they may: OptumRx Prior Authorization Guidelines and Procedures prior authorization (PA), to ensure that they are medically necessary and appropriate for the O4 Footer. endobj Prior authorization Select. <> %PDF-1.7 % Please note: All information below is required to process this request 398 0 obj After that, your optimal prior authorization form is ready. Send filled & signed optiumrx or save. Your patients Other ways to submit a prior authorization, Having difficulties with ePA? denied. $&`vi RHw2e`. Use the Sign Tool to add and create your electronic signature to signNow the Optimal prior authorization form. Step 5 The clinical information window is required. Click thislinkto leverage theAMA's video seriesto educate your staff about the advantages of ePA. It enables a faster turnaround time of coverage determinations for most PA types and reasons. Get Form Now Download PDF Optumrx Prior Authorization Form PDF Details To exercise your rights under HIPAA, click here. (f` pe%TfVAXY.K3`(o]"_0q_fb`` IME: Prior Authorization Form Tips. <>stream OptumRX Prior Prescription Authorization Form Step 2 - The first required information is that of the member. The PDF form you wish to fill out will contain the next areas: Jot down the data in ICD, Codes. If requesting a brand, select the appropriate box. See the ePA Video Overview below to learn more. Submitting a PA request to OptumRx via phone or fax. endobj Select the area where you want to insert your signature and then draw it in the popup window. Click thislinkto leverage theAMA's video seriesto educate your staff about the advantages of ePA. encourage providers to submit PA requests using the ePA process as described 290 0 obj the decision-making process and may result in a denial unless all required information is received. hb``b``*`bd1! <>stream FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED . Step 3 Next, to the right of the member info, supply the healthcare provider info. ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Find OptumRx formularies, formulary updates . If denied, the provider may choose to prescribe a less costly but equally effective, alternative <>/Metadata 3 0 R/Pages 136 0 R/StructTreeRoot 7 0 R/Type/Catalog/ViewerPreferences 159 0 R>> For requests for buy and bill, please contact the patients medical benefit. Supply the diagnosis followed by a list of medications that have been tried and failed and the date on which each drug was prescribed. uuid:94c837f8-2907-48ac-b6be-ad7166d0dcfe %PDF-1.7 % 1-855-427-4682. Draw your signature or initials, place it in the corresponding field and save the changes. Use este formulario para identificar una persona que pueda tomar las decisiones sobre su atencin de la salud, solicitar y divulgar su informacin de salud protegida, o ejercer sus derechos en su nombre. All Rights Reserved. <> Electronic payment solutions; FAQs; Fraud, waste, abuse and general compliance; Forms; Formulary and updates; Guides, manuals and training; Notices; Payer sheets; See all; DPL Main Nav Items. O4 2 Columns (1/2 - 1/2) O4 Text Component. %PDF-1.6 % 3 0 obj Arizona: Commercial Prescription Prior Authorization Form for Prescription Drug, DME-Medical Devices . Who May Make a Request: Find the extension in the Web Store and push, Click on the link to the document you want to design and select. Box 25183 . endobj Press Done after you finish the blank. ), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. Open PDF, . For urgent or expedited requests please call 1-800 -711 -4555. 141 0 obj `HJsCiG:!HY5VX1rAZvdZ Fax Number: 1-844-403-1028 Prior Authorization Department . if it will be covered under your pharmacy benefit. Decide on what kind of signature to create. Enter your official identification and contact details.