2014 OPTUMRx Nuvigil & Provigil Prior Authorization Request Form Fill
Optumrx Tier Exception Form. Generic medications are shown in lowercase (for example, clobetasol). Forms are updated frequently and may be barcoded.
2014 OPTUMRx Nuvigil & Provigil Prior Authorization Request Form Fill
Who may make a request: Do not copy for future use. Please fill out all applicable sections on both pages completely and legibly. Web prescription drug prior authorization or step therapy exception request form patient name: Forms are updated frequently and may be barcoded Web to submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., hcr), please contact the optumrx® pa department through telephone or fax. Web this form may be sent to us by mail or fax: You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). Web partial copay waiver (pcw) exception prior authorization request form. Web fill out every fillable field.
Web prescription drug prior authorization or step therapy exception request form patient name: Web to submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., hcr), please contact the optumrx® pa department through telephone or fax. Your plan may have multiple or no tiers. Member information (required) provider information (required) member name: Forms are updated frequently and may be barcoded Click on the sign tool and make a signature. Who may make a request: You may also ask us for a coverage determination by calling the member services number on the back of your id card. Do not copy for future use. Include the date to the form using the date feature. Web optumrx tier exception form is a request form that allows a patient to request a medication that is a higher tier on their insurance formulary.
