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  • Prior Authorization Request Form/ Interferons/ Hepatitis ... - Optumrx

Get Prior Authorization Request Form/ Interferons/ Hepatitis ... - Optumrx

24/7 Prior Authorization and Specialty Pharmacy Prescription Form Patient Information Patient s Name: Insurance ID: Date of Birth: Height: Address: Weight: Apartment #: City: State: Zip: Phone Number: Alternate Phone: Sex: Provider s Name: Address: Provider ID Number: City: State: Suite Number: Building Number: Phone Number: Fax number: Male Female Provider Information Zip: Provider s Specialty: Medication Information Medication 1: Will the physician supply this me.

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Prescriptions: Most prescription orders are shipped via USPS First Class Mail. Once OptumRx receives your complete order for a new prescription, your medications should arrive within ten business days. Completed refill orders should arrive to your home in about seven business days.

For example, CVS Health operates an insurer (Aetna) and its well-known retail pharmacy chain, as well as CVS Caremark, the PBM subsidiary. Cigna Corp. owns Express Scripts, and UnitedHealth Group, the parent company of UnitedHealthcare, owns Optum Rx.

Optum Rx Prior Authorization Guidelines The ePA solution supports all forms of PA and formulary exception requests. Exclusions may include cost reduction requests such as tiering exception, copay waiver, and tier cost sharing. To submit these requests, please contact our PA department at 1-800-711-4555.

OptumRx and BriovaRx are subsidiaries of UnitedHealth Group. UnitedHealthcare and the dimensional U logo are trademarks of UnitedHealth Group Incorporated. All other trademarks are the property of their respective owners. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.

Assuming you're using a medical provider who participates in your health plan's network, the medical provider's office will make the prior authorization request and work with your insurer to get approval, including handling a possible need to appeal a denial.

All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. Prescription Solutions by OptumRx, the company that administers our health plan's pharmacy benefits, has completed its name change to OptumRx. They are now OptumRx.

Call HealthSelectSM PDP customer service at Optum Rx toll-free at 1-855-828-9834 (TTY: 711). What do I do if my medication needs a PA? To begin the PA process, you can: • Let your doctor know that a PA is needed for your medication. Call Optum Rx toll-free at 1-855-828-9834 (TTY: 711).

The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient's insurance provider. As mentioned in the “How does prior authorization work?” section above, this will then often prompt a time-consuming back and forth between the provider and payer.

OptumRx® and CVS Pharmacy® make it easy for you to get your maintenance medications and may save you money. 1 The OptumRx CVS90 program allows you to get 90-day supplies of your medications at nearly 9,700 CVS Pharmacy locations or through OptumRx home delivery — the choice is yours.

Submitting a PA request to OptumRx via phone or fax above. For urgent requests, please call us at 1-800-711-4555. (Hours: 5am PST to 10pm PST, Monday through Friday.)

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232