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3515 Harbor Blvd., Mail Stop CA1060286, Costa Mesa, CA. 92626 Phone: 18007114555 Fax: 18005270531 Medicare Part D Coverage Determination Request Form This form cannot be used to request: Medicare.

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Fax this form to: 1-866-434-5523 Phone: 1-866-434-5524 OptumRx will provide a response within 24 hours upon receipt.

Prior authorization (PA) requires your doctor to tell us why you are taking a medication to determine if it will be covered under your pharmacy benefit. Some medications must be reviewed because they may: Only be approved or effective for safely treating specific conditions.

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.)

Fax 1-800-491-7997 – Send a complete prescription using the Physician Fax Form.

Pay using credit/debit card or pay by phone using a check. Easy Payment Plan — payment for your 90-day supply is spread over three smaller monthly installments. Reminder. No credit card is needed for $0 copay medications.

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.)

Please call us at 800.753. 2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request.

Call 1-800-791-7658 Provide a verbal prescription directly to Optum Rx pharmacists dedicated to our health care providers.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
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
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
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:
+1 833 426 79 33
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