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Overview

As an OptumRx provider, you know that certain medications require approval,
or prior authorization (PA), to ensure that they are medically necessary and
appropriate for the reason prescribed before they can be covered. PAs help
manage costs, control misuse, and protect patient safety, as well as ensure the
best possible therapeutic outcomes.

PA reviews are completed by clinical pharmacists and/or medical doctors who
base utilization review decisions on sound clinical evidence and make a
determination within the timeframe allowed by state or federal law. Once a
review is complete, the provider is informed whether the PA request has been
approved or denied. If denied, the provider may choose to prescribe a less
costly but equally effective, alternative covered medication, and/or OptumRx
will offer information on the process to appeal the adverse decision.
 

OptumRx Prior Authorization Guidelines

The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior
authorization (PA) guidelines* to encompass assessment of drug indications, set guideline
types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective
dates and more. Guidelines are based on written objective pharmaceutical UM decision-
making criteria** that are developed from clinical evidence from the following sources:

  • Food and Drug Administration (FDA) information
  • Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-
    analyses, review articles, comparative effectiveness research, evidence-based medicine
    reviews, healthcare technology assessments, and pharmacoeconomic and outcomes
    research
  • Treatment guidelines, practice parameters, policy statements, consensus statements
    created/endorsed by reputable governmental, medical, and/or pharmacy organizations
  • Pharmaceutical, device, and/or biotech company information
  • Medical and pharmacy tertiary resources, including those recognized by CMS
  • Relevant and reputable medical and pharmacy textbooks and or websites

*Guidelines are specific to plans utilizing our standard drug lists only. Your patient’s
prescription drug benefits may be covered under his/her plan-specific formulary for which
these guidelines may not apply.  We recommend you speak with your patient regarding
prescription drug benefit coverage under his/her health insurance plan or call OptumRx.

** OptumRx’s Senior Medical Director provides ongoing evaluation and quality assessment of
the OptumRx UM Program.


How to access the OptumRx PA guidelines:

  • Reference the OptumRx electronic prior authorization (ePA ) and (fax) forms
    which contain clinical information used to evaluate the PA request as part of
    the determination process.
  • Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed
    or mailed to you.
  • Click here to review PA guideline changes.

** OptumRx’s Senior Medical Director provides ongoing evaluation and quality
assessment of the OptumRx UM Program.


OptumRx Prior Authorization and 
Exception Request Procedures

Submitting an electronic prior authorization (ePA) request to OptumRx                                                    

ePA is a secure and easy method for submitting,managing, tracking PAs, step
therapy and non-formulary exception requests. It enables a faster turnaround time of
coverage determinations for most PA types and reasons.

Login to your preferred web-based portal account and select “New Request”within
your Dashboard to submit your PA request.


Submitting a PA request to OptumRx via phone or fax

As part of an ongoing effort to increase security, accuracy, and timeliness of PA
requests and determinations, OptumRx is retiring most fax numbers used for
submitting pharmacy prior authorization requests for all plans managed by
OptumRx, except for the following states:  MA, RI, SC, and TX. We strongly
encourage providers to submit PA requests using the ePA process as described
above.

If providers are unable to submit electronically, we offer the following options:

Call 1-800-711-4555 to submit a verbal PA request
View and print a PA request form

For urgent requests, please call us at 1-800-711-4555.
(Hours: 5am PST to 10pm PST, Monday through Friday.)