Medicare Part D prior authorization forms

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. 

• General Form 
• Benzodiazepines
• Hospice form – Use this form for hospice enrollees
  
• Opioids (UnitedHealthcare Medicare only) - Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.
• Opioids- Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits
• Tier Cost Form