If you cannot submit requests through electronic prior authorization (ePA), or for urgent requests, please call us at 1-800-711-4555.
Hours: 5am PST to 10pm PST, Monday through Friday
Otherwise, you can submit requests to the OptumRx® Prior Authorization Department by completing and faxing the applicable form.
The hospice form should be used for hospice enrollees. Please complete this form along with a drug-specific form found below, when available.
E
- Effexor XR
- Elidel
- Emgality
- Enbrel
- Endocet
- Epclusa
- epinephrine injection
- EpiPen
- EpiPen Jr.
- 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
- Exelon patch
- Farxiga
- 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 patch
- Fexmid
- Fibricor
- Fioricet
- Flector
- fluoxetine tablet
- Fortamet
- Forteo
T
- tacrolimus ointment
- tadalafil (generic Cialis)
- tadalafil (generic Adcirca)
- Taltz
- temazepam
- Tirosint
- Tirosint-Sol
- tolterodine ER
- tramadol
- tramadol ER
- tramadol-acetaminophen
- Trelegy Ellipta
- Tremfya
- Tresiba
- tretinoin cream
- tretinoin gel (generic Atralin)
- tretinoin gel (generic Retin-A)
- tretinoin microsphere
- tretinoin microsphere pump
- Tricor
- Triglide
- Trilipix
- Trulance
- Trulicity
- Tymlos
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)
Top