Prescribers can submit requests to the OptumRx® prior authorization department by completing the applicable form (Part D, UnitedHealthcare or OptumRx) and faxing it to 1-800-527-0531. For urgent requests, call 1-800-711-4555.
Hours: 5 a.m. PST to 10 p.m. PST, Monday through Friday
The hospice form should be used for hospice enrollees. Please complete this form along with a drug-specific form found below, when available.
A
- abiraterone acetate (generic Zytiga)
- Abstral
- Actemra
- Actiq
- Adcirca
- Adderall
- Adderall XR
- Adempas
- Admelog (United Healthcare Medicare only)
- Admelog
- Admelog SoloStar (UnitedHealthcare Medicare only)
- Admelog SoloStar
- Adrenaclick
- Advair Diskus
- Advair HFA
- Afinitor
- Afinitor Disperz
- Aimovig
- Ajovy
- albuterol HFA
- albuterol nebulizer solution
- Alecensa
- Allzital
- alprazolam
- alprazolam ER
- alprazolam intensol
- alprazolam ODT
- Ambien
- Ambien CR
- Amitiza
- amitriptyline
- amphetamine-dextroamphetamine
- amphetamine-dextroamphetamine ER
- Ampyra
- Amrix
- Androderm
- Androgel
- Androgel Pump
- Android
- Antara
- Apidra SoloStar (UnitedHealthcare Medicare only)
- Apidra SoloStar
- Apidra vial (UnitedHealthcare Medicare only)
- Apidra vial
- Apokyn
- Aralast NP
- Aranesp
- Aredia
- Armodafinil
- Arymo ER
- Ascomp-codeine
- Atacand
- Atacand HCT
- Ativan
- atorvastatin
- Atralin
- Aubagio
- Auryxia
- Austedo
- Auvi-Q
- Avastin
- Aveed
- Avonex
- Azasan (azathioprine)
B
- Basaglar KwikPen
- Belbuca
- Benicar
- Benicar HCT
- Benlysta
- Bethkis
- Boniva
- Botox
- budesonide ER tablet
- budesonide nebulizer suspension
- Bunavail
- Bupap
- buprenorphine patch
- buprenorphine-naloxone
- butalbital-acetaminophen
- butalbital-acetaminophen-caffeine
- butalbital-acetaminophen-caffeine-codeine
- butalbital-aspirin-caffeine
- butalbital-aspirin-caffeine-codeine
- Butrans
- Bydureon
- Bydureon BCise
- Bystolic
- Cabometyx
- Calquence
- candesartan
- candesartan/ HCTZ
- Capacet
- carisoprodol
- carisoprodol-aspirin
- Celebrex
- celecoxib
- Cellcept
- Cesamet
- chlorzoxazone
- Cialis
- Ciclodan
- Ciclopirox
- Cimzia
- Climara
- clobetasol
- Combigan
- Conzip
- Copaxone
- Cosentyx
- Crestor
- cyclobenzaprine
- cyclobenzaprine ER
- cyclosporine (generic Sandimmune)
- cyclosporine modified (generic Neoral)
- Cymbalta
D
- Daliresp
- dalfampridine ER (generic Ampyra)
- darifenacin
- Depo-Testosterone
- desonide cream
- desonide lotion
- Desowen cream
- Desowen lotion
- Detrol
- Detrol LA
- Dexilant
- Diabetic Testing Supplies
- diclofenac 3% gel
- diclofenac epolamine
- diclofenac topical solution
- dicyclomine
- Digitek
- Digox
- digoxin
- Dilaudid
- diltiazem ER
- diphenoxylate-atropine
- Ditropan XL
- Dolophine
- Doptelet
- doxepin capsule and solution
- dronabinol
- Dulera
- Duloxetine
- Dupixent
- Duragesic
- Dysport
E
- Effexor XR
- Egrifta
- Elidel
- Eligard
- Emgality
- Enablex
- Enbrel
- Endocet
- Entyvio
- Epclusa
- Epidiolex
- epinephrine injection
- EpiPen
- EpiPen Jr.
- Epogen
- Eprosartan
- Erivedge
- Erleada
- Esbriet
- Esgic
- esomeprazole magnesium (generic Nexium)
- Estrace tablet and vaginal cream
- estradiol (generic Estrace tablet and vaginal cream)
- estradiol patch (generic Climara)
- estradiol patch (generic Vivelle-Dot)
- estradiol vaginal tablet (generic Vagifem)
- eszopiclone
- Eucrisa
- Euflexxa
- Evzio
- Exelon patch
- famotidine suspension
- famotidine tablet
- Farxiga
- Fasenra
- fenofibrate (generic Fenoglide)
- fenofibrate (generic Lipofen)
- fenofibrate (generic Lofibra tablet)
- fenofibrate (generic Tricor)
- fenofibrate (micronized) [generic Antara]
- fenofibrate (micronized) [generic Lofibra capsule]
- fenofibric acid
- fenofibric acid DR
- Fenoglide
- fentanyl lozenge
- fentanyl patch
- Fentora
- Fexmid
- Fiasp FlexTouch (UnitedHealthcare Medicare only)
- Fiasp FlexTouch
- Fiasp vial (United Healthcare Medicare only)
- Fiasp vial
- Fibricor
- Fioricet
- Fioricet-codeine
- Fiorinal
- Fiorinal-codeine
- Flector
- Flovent Diskus
- Flovent HFA
- fluoxetine tablet
- fluoxetine tablet (generic Sarafem)
- Fortamet
- Forteo
- Fortesta
- Fulphila
G
- Gattex
- Gelnique
- Gel-One
- Gengraf
- Genotropin
- Genvisc
- Gilotrif
- Glassia
- glatiramer acetate
- Glatopa
- Gleevec
- Glucophage XR
- Glucovance
- Glumetza
- glyburide
- glyburide-metformin
- glyburide (micronized)
- glycopyrrolate
- Glynase
- Gralise
- Gralise Starter Pack
J
- lamotrigine ER
- Lanoxin
- lansoprazole
- lansoprazole ODT
- Lantus
- Lantus Solostar
- Lazanda
- ledipasvir/sofosbuvir (generic Harvoni)
- Lenvima
- Letairis
- levalbuterol HFA
- Levemir FlexTouch
- Levemir vial
- lidocaine topical patch
- Lidoderm
- linezolid suspension and tablet
- Lipitor
- Lipofen
- Livalo
- Lofibra capsule
- Lofibra tablet
- Lomotil
- Lonsurf
- lorazepam
- Lorcet
- Lorcet HD
- Lorcet Plus
- Lortab
- Lorzone
- Lotemax
- Lucentis
- Lumigan
- Lunesta
- Lupron Depot
- Lupron Depot-Ped
- Lynparza
M
- Marinol
- Mavyret
- meclizine
- Megace ES
- megestrol ES suspension
- megestrol suspension and tablet
- Mekinist
- Mektovi
- memantine ER
- memantine IR solution
- memantine IR tablet
- memantine IR titration pack
- Menostar
- Metaxall
- metaxalone
- Metformin ER (generic Fortamet, Glumetza, & Glucophage XR)
- methadone
- methadone intensol
- Methadose
- Methitest
- methocarbamol
- methylphenidate ER capsule
- methylphenidate ER tablet
- methyltestosterone
- modafinil
- Monovisc
- Monurol
- Morphabond ER
- morphine sulfate ER
- morphine sulfate IR
- Movantik
- MS Contin
- mycophenolate mofetil (generic Cellcept)
- mycophenolic acid (generic Myfortic)
- Myfortic
- Myrbetriq
- Nalocet
- Namenda IR solution
- Namenda IR tablet
- Namenda IR titration pack
- Namenda XR
- Namenda XR titration pack
- Natesto
- Neoral
- Neulasta
- Nexavar
- Nexium
- Nexium packet
- nifedipine ER
- Ninlaro
- Norco
- Norditropin
- Norgesic Forte
- Northera
- nortriptyline
- Novantrone
- Novolin 70/30 FlexPen
- Novolin 70/30 FlexPen Relion
- Novolin Mix 70/30
- Novolin Mix 70/30 Relion
- Novolin N
- Novolin N Relion
- Novolin R
- Novolin R Relion
- NovoLog FlexPen
- NovoLog Mix 70/30 FlexPen
- NovoLog Mix 70/30 vial
- NovoLog Penfill
- NovoLog vial
- Nucala
- Nucynta
- Nuplazid
- Nutropin AQ
- Nuvigil
- nystatin-triamcinolone
O
- Ocrevus
- octreotide acetate
- Ofev
- olmesartan
- olmesartan-hydrochlorothiazide
- Olumiant
- omeprazole
- omeprazole/sodium bicarbonate
- OmniPod
- ondansetron
- ondansetron ODT
- ondansetron oral solution
- Onmel
- Opana ER (crush resistant)
- Opdivo
- Opsumit
- Orencia
- Orenitram
- orphenadrine ER
- Orthovisc
- Osphena
- Otezla
- Otrexup
- Oxervate
- oxycodone ER
- oxycodone IR capsule
- oxycodone IR concentrate
- oxycodone IR solution
- oxycodone IR tablet
- oxycodone-acetaminophen
- OxyContin (UnitedHealthcare Medicare only)
- OxyContin
- oxymorphone ER
- Oxytrol
- Ozempic
- Pamelor
- pantoprazole
- paroxetine
- paroxetine ER
- Paxil
- Paxil CR
- Pegasys
- Penlac Nail Lacquer
- Pennsaid
- Percocet
- Pexeva
- Phrenilin Forte
- pimecrolimus
- Plegridy
- Pomalyst
- potassium chloride ER capsule
- Praluent
- Premarin
- Prevacid
- Prevacid SoluTab
- Prevymis
- Prilosec
- Primlev
- Proair HFA
- Proair Respiclick
- Procrit
- Prograf
- Prolastin C
- Promacta
- Protonix
- Protonix suspension
- Protopic
- Proventil HFA
- Provigil
- Pulmicort Flexhaler
- Pulmicort Respules
- Radicava
- ranitidine capsule
- ranitidine syrup
- Rapamune
- Rasuvo
- Regranex
- Relistor
- Remicade
- Repatha
- Restoril
- Retacrit
- Retin-A
- Retin-A Micro
- Retin-A Micro Pump
- Revatio
- Revlimid
- Rhopressa
- Rituxan
- rivastigmine patch
- Robaxin
- Robaxin-750
- Robinul
- Robinul Forte
- rosuvastatin
- Roxicodone
- Roxybond
- Rubraca
- Rytary
- Samsca
- Sandimmune
- Sandostatin
- Sandostatin LAR Depot
- Sarafem
- scopolamine
- Seroquel XR
- Serostim
- Shingrix
- sildenafil citrate
- Siliq
- Simponi, Simponi Aria
- sirolimus (generic Rapamune)
- Skelaxin
- sodium chloride inhalation solution
- sofosbuvir/velpatasvir (generic Epclusa)
- solifenacin
- Soma
- Soolantra
- Sporanox
- Sporanox oral solution
- Sporanox Pulse Pack
- Sprycel
- Stelara
- Stivarga
- Striant
- Suboxone
- Subsys
- Supartz/Supartz FX
- Sutent
- Symbicort
- Symjepi
- Symproic
- Syndros
- Synthroid
T
- tacrolimus capsule
- tacrolimus ointment
- tadalafil
- tadalafil (for Pulmonary Arterial Hypertension)
- Tafinlar
- Tagrisso
- Taltz
- Tasigna
- Tecfidera
- temazepam
- Tencon
- Testim
- Testone CIK
- Testopel
- testosterone 10mg/actuation (2%) gel
- testosterone cypionate
- testosterone enanthate
- testosterone solution (generic Axiron)
- testosterone topical gel (generic Androgel, Testim, and Vogelxo)
- testosterone topical gel pump (generic Androgel pump and Vogelxo pump)
- Testred
- tetrabenazine
- Tirosint
- Tirosint-Sol
- tizanidine capsule
- Tobi
- Tobi Podhaler
- tobramycin inhalation
- Tolsura
- tolterodine
- tolterodine ER
- Toviaz
- tramadol
- tramadol ER
- tramadol-acetaminophen
- Transderm Scop
- Trelegy Ellipta
- Tremfya
- Tresiba
- tretinoin cream
- tretinoin gel (generic Atralin)
- tretinoin gel (generic Retin-A)
- tretinoin microsphere
- tretinoin microsphere pump
- Tricor
- Triglide
- Trilipix
- trospium
- trospium ER
- Trulance
- Trulicity
- Tudorza Pressair
- Tykerb
- Tymlos
- Tysabri
V
- Vagifem
- Vanatol LQ
- Vanatol S
- Venclexta
- venlafaxine ER tablet
- Ventolin HFA
- Verzenio
- Vesicare
- Viberzi
- Vicodin
- Vicodin ES
- Vicodin HP
- Victoza
- Visco-3
- Vistaril
- Vivelle-Dot
- Vogelxo
- Vogelxo pump
- Voltaren gel
- Vosevi
- Votrient
- Vraylar
- Vyvanse
- Xanax
- Xanax XR
- Xeljanz
- Xgeva
- Xifaxan
- Xiidra
- Xodol
- Xolair
- Xopenex HFA
- Xtampza ER
- Xtandi
- Xyosted
- Xyrem
Other Forms
- The General Form should be used when a drug-specific form is not available from the list above.
- Tier Cost Form
- Opioid Overrides (MME, 7 day supply limit, combination opioid use, duplicate long-acting opioid use) [UnitedHealthcare Medicare only]
- Opioid Overrides (MME, 7 day supply limit, combination opioid use, duplicate long-acting opioid use)
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