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)
- Abraxane
- Abstral
- Acanya
- Acetylcysteine inhalation solution
- Aciphex
- Aciphex Sprinkle
- Actemra
- Actiq
- Activella
- Actonel
- adapalene cream
- adapalene gel
- adapalene lotion
- adapalene-benzoyl peroxide
- Adcirca
- Adderall
- Adderall XR
- Adempas
- Admelog (United Healthcare Medicare only)
- Admelog
- Admelog SoloStar (UnitedHealthcare Medicare only)
- Admelog SoloStar
- Adrenaclick
- Advair Diskus
- Advair HFA
- Aerospan
- Afinitor
- Afinitor Disperz
- Afrezza
- Aimovig
- Ajovy
- Akynzeo
- albuterol HFA
- albuterol nebulizer solution
- Alecensa
- Allzital
- almotriptan
- Alora
- alosetron
- Alphagan P
- alprazolam
- alprazolam ER
- alprazolam intensol
- alprazolam ODT
- Altoprev
- Alunbrig
- Alvesco
- Amabelz
- Ambien
- Ambien CR
- Amerge
- Amitiza
- amitriptyline
- amlodipine-benazepril
- amphetamine-dextroamphetamine
- amphetamine-dextroamphetamine ER
- Ampyra
- Amrix
- Anafranil
- Androderm
- Androgel
- Androgel Pump
- Android
- Antara
- Apidra SoloStar (UnitedHealthcare Medicare only)
- Apidra SoloStar
- Apidra vial (UnitedHealthcare Medicare only)
- Apidra vial
- Apokyn
- aprepitant
- Aralast NP
- Aranesp
- Aredia
- Armodafinil
- ArmonAir RespiClick
- Arthrotec 50
- Arthrotec 75
- Arymo ER
- Arzerra
- Asacol HD
- Ascomp-codeine
- Asmanex HFA
- Asmanex Twisthaler
- Astagraf XL
- Atacand
- Atacand HCT
- Ativan
- atomoxetine
- atorvastatin
- Atralin
- Aubagio
- Auryxia
- Austedo
- Auvi-Q
- Avastin
- Aveed
- Avonex
- Axert
- Azasan (azathioprine)
- azelaic acid
B
- Basaglar KwikPen
- Belbuca
- Bendeka (bendamustine)
- Benicar
- Benicar HCT
- Benlysta
- benztropine
- Berinert
- Betaseron
- Bethkis
- bexarotene (generic Targretin)
- Boniva
- bortezomib
- Bosulif
- Botox
- Braftovi
- brimonidine
- Brovana
- 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
- carbinoxamine
- carisoprodol
- carisoprodol-aspirin
- carisoprodol-aspirin-codeine
- carvedilol phosphate ER
- Cayston
- Celebrex
- celecoxib
- Cellcept
- Cesamet
- cevimeline
- chlordiazepoxide-amitriptyline
- chlorzoxazone
- chorionic gonadotropin
- Cialis
- Ciclodan
- Ciclopirox
- Cimzia
- Cinryze
- clemastine
- Climara
- Climara Pro
- clindamycin-benzoyl peroxide 1.2-2.5%
- clindamycin-tretinoin
- clobetasol
- clomipramine
- clonazepam
- clonazepam ODT
- colesevelam
- Combigan
- Combipatch
- Cometriq
- Conzip
- Copaxone
- Copiktra
- Coreg CR
- Corlanor
- Cosentyx
- Cosopt
- Cosopt PF
- Cotellic
- Crestor
- cromolyn nebulizer solution
- cyclobenzaprine
- cyclosporine (generic Sandimmune)
- cyclosporine modified (generic Neoral)
- Cymbalta
- cyproheptadine
- Cyramza
D
- Daklinza
- Daliresp
- dalfampridine ER (generic Ampyra)
- Dalvance
- Darzalex
- darifenacin
- Daurismo
- Delzicol
- Demerol
- Depo-Testosterone
- desonide cream
- desonide lotion
- Desowen cream
- Desowen lotion
- desvenlafaxine ER
- desvenlafaxine succinate ER (generic Pristiq)
- Detrol
- Detrol LA
- Dexilant
- dexrazoxane
- Diabetic Testing Supplies
- diazepam
- diazepam intensol concentrate
- diclofenac 3% gel
- diclofenac gel (generic Voltaren)
- diclofenac topical solution (generic Pennsaid)
- diclofenac-misoprostol
- dicyclomine
- Differin
- Digitek
- Digox
- digoxin
- Dilaudid
- diltiazem ER
- diphenoxylate-atropine
- disopyramide
- Ditropan XL
- Divigel
- Dolophine
- Doptelet
- doxepin capsule and solution
- dronabinol
- Duexis
- Dulera
- Duloxetine
- Dupixent
- Duragesic
- Dymista
- Dysport
E
- Effexor XR
- Egrifta
- eletriptan
- Elidel
- Eligard
- Emend
- Emend TriPack
- Emflaza
- Emgality
- Enablex
- Enbrel
- Endocet
- Entresto
- Entyvio
- Envarsus XR
- Epclusa
- Epidiolex
- Epiduo
- Epiduo Forte
- epinephrine injection
- EpiPen
- EpiPen Jr.
- Epogen
- Eprosartan
- Erbitux
- Erivedge
- Erleada
- Esbriet
- Esgic
- esomeprazole magnesium (generic Nexium)
- estazolam
- Estrace tablet and vaginal cream
- estradiol (generic Estrace tablet and vaginal cream)
- estradiol patch (generic Climara)
- estradiol patch (generic Vivelle-Dot)
- estradiol-norethindrone (generic Activella)
- estradiol vaginal tablet (generic Vagifem)
- estropipate
- eszopiclone
- Eucrisa
- Euflexxa
- Evamist
- Evoxac
- Evzio
- Exalgo
- Exelon patch
- Exondys51
- Extavia
- ezetimibe-simvastatin
- famotidine suspension
- famotidine tablet
- Farxiga
- Fasenra
- Femhrt Low Dose
- 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
- Finacea
- Fioricet
- Fioricet-codeine
- Fiorinal
- Fiorinal-codeine
- Firazyr
- Firmagon
- Flector
- FloLipid
- Flovent Diskus
- Flovent HFA
- fluoxetine tablet
- fluoxetine tablet (generic Sarafem)
- flurazepam
- fluvastatin
- fluvastatin ER
- Fortamet
- Forteo
- Fortesta
- Frova
- frovatriptan
- Fulphila
- Furadantin
G
- Gamifant
- Gattex
- Gazyva
- Gelnique
- Gel-One
- Gengraf
- Genotropin
- Genvisc
- Gilenya
- Gilotrif
- Glassia
- glatiramer acetate
- Glatopa
- Gleevec
- Glucophage XR
- Glucovance
- Glumetza
- glyburide
- glyburide-metformin
- glyburide (micronized)
- glycopyrrolate
- Glynase
- Gralise
- Gralise Starter Pack
- granisetron tablet
- guanfacine
- guanfacine ER
- Haegarda
- Halaven
- Halcion
- Harvoni
- Herceptin
- Hetlioz
- Horizant
- H.P. Acthar
- Humatrope
- Humira
- Hyalgan
- hydrocodone-acetaminophen
- hydrocodone-ibuprofen
- hydromorphone
- hydromorphone ER
- hydroxyprogesterone caproate
- hydroxyzine hydrochloride solution and tablet
- hydroxyzine pamoate
- Hymovis
- HyperSal
- Hysingla ER
- Ibrance
- Ibudone
- Iclusig
- Idhifa
- Ilaris
- Ilumya
- imatinib
- Imbruvica
- Imfinzi
- imipramine hydrochloride
- imipramine pamoate
- Imitrex nasal solution
- Imitrex tablet
- Immune Globulins
- Incruse Ellipta
- Indocin suspension
- indomethacin
- indomethacin ER
- Inflectra
- Ingrezza
- Inlyta
- Intermezzo
- Intrarosa
- Intron-A
- Intuniv
- Invokamet
- Invokamet XR
- Invokana
- ipratropium nebulizer solution
- ipratropium-albuterol nebulizer solution
- Iressa
- Istodax
- itraconazole
J
- Kadcyla
- Kadian
- Kalbitor
- Kalydeco
- Karbinal ER
- ketorolac
- Keveyis
- Kevzara
- Keytruda
- Khedezla
- Kineret
- Kisqali, Kisqali Femara
- Kitabis Pak
- Klonopin
- Korlym
- Kyprolis
- Lamictal
- lamotrigine ER
- Lanoxin
- lansoprazole
- lansoprazole ODT
- lansoprazole/amoxicillin/clarithromycin
- Lantus
- Lantus Solostar
- Lartruvo
- Lazanda
- ledipasvir/sofosbuvir (generic Harvoni)
- Lemtrada
- Lenvima
- Lescol
- Lescol XL
- Letairis
- Leukine
- levalbuterol HFA
- levalbuterol nebulizer solution
- Levemir FlexTouch
- Levemir vial
- Lexapro
- Lialda
- Libtayo
- lidocaine topical patch
- Lidoderm
- linezolid injection
- linezolid suspension and tablet
- Lipitor
- Lipofen
- Livalo
- Lofibra capsule
- Lofibra tablet
- Lomotil
- Lonsurf
- lorazepam
- Lorcet
- Lorcet HD
- Lorcet Plus
- Lortab
- Lorzone
- Lotemax
- Lotrel
- Lotronex
- Lucentis
- Lumigan
- Lunesta
- Lupron Depot
- Lupron Depot-Ped
- Lynparza
M
- Macrobid
- Macrodantin
- Makena
- Marinol
- Marten-Tab
- Mavyret
- Maxalt
- Maxalt MLT
- Mayzent
- meclizine
- Megace ES
- megestrol ES suspension
- megestrol suspension and tablet
- Mekinist
- Mektovi
- memantine ER
- memantine IR solution
- memantine IR tablet
- memantine IR titration pack
- Menest
- Menostar
- meperidine
- meprobamate
- mesalamine 800mg DR tablet
- mesalamine 1.2g DR tablet
- Metaxall
- metaxalone
- Metformin ER (generic Fortamet, Glumetza, & Glucophage XR)
- methadone
- methadone intensol
- Methadose
- Methitest
- methocarbamol
- methylphenidate ER capsule
- methylphenidate ER tablet
- methyltestosterone
- Miacalcin
- Mimvey
- Mimvey Lo
- Minivelle
- Mircera
- modafinil
- Monovisc
- Monurol
- Morphabond ER
- morphine sulfate ER
- morphine sulfate IR
- Movantik
- MS Contin
- Mulpleta
- Multaq
- mycophenolate mofetil (generic Cellcept)
- mycophenolic acid (generic Myfortic)
- Myfortic
- Myobloc
- Myrbetriq
- Nalocet
- Namenda IR solution
- Namenda IR tablet
- Namenda IR titration pack
- Namenda XR
- Namenda XR titration pack
- naratriptan
- Natesto
- Natpara
- NebuSal
- Neoral
- Nerlynx
- Neulasta
- Nexavar
- Nexium
- Nexium packet
- nifedipine
- nifedipine ER
- Ninlaro
- nitrofurantoin macrocrystalline
- nitrofurantoin monohydrate
- nitrofurantoin suspension
- Noctiva
- Norco
- Norditropin
- norethindrone acetate-ethinyl estradiol (generic Femhrt)
- Norpace
- Norpace CR
- Northera
- nortriptyline
- Novantrone
- Novarel
- 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
- Nplate
- Nucala
- Nucynta
- Nucynta ER
- Nulojix
- Nuplazid
- Nutropin AQ
- Nuvigil
- nystatin-triamcinolone
O
- Ocrevus
- octreotide acetate
- Ofev
- olmesartan
- olmesartan-hydrochlorothiazide
- omeprazole
- omeprazole/sodium bicarbonate
- OmniPod
- Omnitrope
- ondansetron
- ondansetron ODT
- ondansetron oral solution
- Onglyza
- Onmel
- Onzetra Xsail
- Opana
- Opana ER (crush resistant)
- Opdivo
- Opsumit
- Orencia
- Orenitram
- Orkambi
- orphenadrine ER
- Orthovisc
- Osphena
- Otezla
- Otrexup
- oxazepam
- oxycodone ER
- oxycodone IR capsule
- oxycodone IR concentrate
- oxycodone IR solution
- oxycodone IR tablet
- oxycodone-acetaminophen
- OxyContin (UnitedHealthcare Medicare only)
- OxyContin
- oxymorphone
- oxymorphone ER
- Oxytrol
- Ozempic
- Pamelor
- pantoprazole
- Parafon Forte DSC
- paroxetine
- paroxetine ER
- Paxil
- Paxil CR
- Pegasys
- Peg-Intron
- Penlac Nail Lacquer
- Pennsaid
- pentazocine-naloxone
- Percocet
- Perforomist
- Perjeta
- perphenazine-amitriptyline
- Pexeva
- Phenadoz
- Phenergan
- phenobarbital elixir and tablet
- Phrenilin Forte
- pimecrolimus
- Plegridy
- Pomalyst
- potassium chloride ER capsule
- Pradaxa
- Praluent
- Pregnyl
- Premarin
- Prempro
- Prevacid
- Prevacid SoluTab
- Prevymis
- Prilosec
- Primlev
- Pristiq
- Proair HFA
- Proair Respiclick
- Procardia
- Procrit
- progesterone
- Prograf
- Prolastin C
- Promacta
- promethazine-phenylephrine
- promethazine solution
- promethazine suppository
- promethazine syrup
- promethazine tablet
- promethazine VC
- Promethegan
- Protonix
- Protonix suspension
- Protopic
- Proventil HFA
- Provigil
- Pulmicort Flexhaler
- Pulmicort Respules
- PulmoSal
- Pulmozyme
- Pylera
- rabeprazole
- Radicava
- ranitidine capsule
- ranitidine syrup
- Rapamune
- Rasuvo
- Rebif
- Regranex
- Relistor
- Relpax
- Remicade
- Repatha
- Requip XL
- Restoril
- Retacrit
- Retin-A
- Retin-A Micro
- Retin-A Micro Pump
- Revatio
- Revlimid
- Rhopressa
- risedronate
- Rituxan
- Rituxan Hycela
- rivastigmine patch
- rizatriptan
- rizatriptan ODT
- Robaxin
- Robaxin-750
- Robinul
- Robinul Forte
- ropinirole ER
- rosuvastatin
- Roxicodone
- Roxybond
- Rubraca
- Ruconest
- Rydapt
- Rytary
- Sabril
- Saizen
- Samsca
- Sancuso
- Sandimmune
- Sandostatin
- Sandostatin LAR Depot
- Sarafem
- Savaysa
- scopolamine
- Segluromet
- Seroquel
- Seroquel XR
- Serostim
- Shingrix
- sildenafil citrate
- Silenor
- Siliq
- Simbrinza
- Simponi, Simponi Aria
- simvastatin
- Singulair
- sirolimus (generic Rapamune)
- Skelaxin
- sodium chloride inhalation solution
- sofosbuvir/velpatasvir (generic Epclusa)
- Soliris
- Soma
- Sonata
- Soolantra
- Sovaldi
- Sporanox
- Sporanox oral solution
- Sporanox Pulse Pack
- Sprycel
- Steglatro
- Steglujan
- Stelara
- Stivarga
- Strattera
- Striant
- Suboxone
- Subsys
- sumatriptan nasal spray
- sumatriptan-naproxen
- sumatriptan tablet
- Supartz/Supartz FX
- Sutent
- Symbicort
- Symdeko
- Symjepi
- Symproic
- Syndros
- Synribo
- Synthroid
T
- tacrolimus capsule
- tacrolimus ointment
- tadalafil
- tadalafil (for Pulmonary Arterial Hypertension)
- Tafinlar
- Tagrisso
- Takhzyro
- Taltz
- Talzenna
- Tanzeum
- Tarceva
- Targretin
- Tasigna
- Tavalisse
- tazarotene
- Tazorac
- Tecentriq
- Tecfidera
- Technivie
- 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
- Thalomid
- Thyrogen
- Tibsovo
- Tigan
- Tirosint
- Tivorbex
- tizanidine capsule
- Tobi
- Tobi Podhaler
- tobramycin inhalation
- Tofranil
- Tolsura
- tolterodine
- tolterodine ER
- Topamax
- Topamax Sprinkle
- Toprol XL
- Totect
- Toviaz
- Tracleer
- Tradjenta
- tramadol
- tramadol ER
- tramadol-acetaminophen
- Transderm Scop
- Travatan Z
- Trelegy Ellipta
- Trelstar
- Trelstar Mixject
- Tremfya
- Tresiba
- tretinoin cream
- tretinoin gel (generic Atralin)
- tretinoin gel (generic Retin-A)
- tretinoin microsphere
- tretinoin microsphere pump
- Treximet
- triazolam
- Tricor
- Triglide
- trihexyphenidyl elixir and tablet
- Trilipix
- trimethobenzamide
- Triptodur
- Trokendi XR
- trospium
- trospium ER
- Trulance
- Trulicity
- Tudorza Pressair
- Tykerb
- Tymlos
- Tysabri
V
- Vagifem
- Valchlor
- Valium
- Vanatol LQ
- Vanatol S
- Varizig
- Varubi
- Vectibix
- Velcade
- Venclexta
- venlafaxine ER tablet
- Ventolin HFA
- Verzenio
- Vesicare
- Viberzi
- Vicodin
- Vicodin ES
- Vicodin HP
- Victoza
- Viekira Pak
- Viekira XR
- vigabatrin (generic Sabril)/Vigadrone
- Vimizim
- Visco-3
- Vistaril
- Vitrakvi
- Vivelle-Dot
- Vizimpro
- Vogelxo
- Vogelxo pump
- Voltaren gel
- Vosevi
- Votrient
- Vraylar
- Vytorin
- Vyvanse
- Vyzulta
- Xalkori
- Xanax
- Xanax XR
- Xeljanz
- Xeljanz XR
- Xenazine
- Xeomin
- Xermelo
- Xgeva
- Xifaxan
- Xigduo XR
- Xiidra
- Xodol
- Xolair
- Xopenex HFA
- Xopenex nebulizer solution
- Xtampza ER
- Xtandi
- Xultophy
- Xylon
- Xyosted
- Xyrem
Z
- zaleplon
- Zamicet
- Zanaflex capsule
- Zanaflex tablet
- Zebutal
- Zegerid
- Zegerid suspension
- Zejula
- Zelboraf
- Zemaira
- Zepatier
- Ziana
- Zinbryta
- Zinecard
- Zocor
- Zofran ODT
- Zofran oral solution
- Zofran tablet
- Zohydro ER
- Zolinza
- zolmitriptan
- zolmitriptan ODT
- zolpidem
- zolpidem ER
- zolpidem sublingual tablet
- Zomacton
- Zomig
- Zomig nasal spray
- Zomig ZMT
- Zorbtive
- Zortress
- Zostavax
- ZTlido
- Zubsolv
- Zuplenz
- Zydelig
- Zykadia
- Zypitamag
- Zytiga
- Zyvox injection
- Zyvox suspension and tablet
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