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Prior Authorization Form General/Non-Preferred Drugs Access this PA form at: ... Buprenorphine Products Celebrex Compounds Daklinza Diabetic Supplies Dipeptidyl-Peptidase IV Inhibitors Growth Hormones Harvoni High Potency Statins Incretin Mimetics Influenza Antivirals I/DD Worksheet Long Acting Narcotics
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Preferred Drug List (PDL)
www.optumrx.comPA – Prior Authorization required, subject to specific PA criteria; QL – Quantity Limit (PA & NP agents require a PA before dispensing); B – Budgetary Reduction edit for utilization control (Standard NP PA criteria does not apply); ID – Class PA for patients with Intellectual or Developmental Disability
New PrescriPtioN Mail-iN order ForM 1 Member and …
www.optumrx.comOver-the-counter/herbal medications taken regularly: Pharmacy processing ... Payment and shipping information — do not send cash ... New prescriptions should arrive within about 10 business days from the date the completed order is received. Completed refill orders should arrive within about 7 business days.
2021 Preventive medications and your plan
www.optumrx.comlosartan potassium losartan potassium / hctz matzim la methyclothiazide methyldopa methyldopa / hctz metolazone metoprolol er metoprolol minoxidil tablet moexipril nadolol nadolol / bendroflumethiazide nicardipine nifedipine nifedipine er nimodipine nisoldipine er olmesartan olmesartan / amlodipine / hctz olmesartan / hctz
Prescription Reimbursement Request Form - OptumRx
www.optumrx.comPRESCRIPTION REIMBURSEMENT REQUEST FORM ... I did not use my Prescription Drug ID card I used a non-participating pharmacy (please explain) ... Section C – Coordination of benefits You must submit claims within one year of date of purchase or as required by your plan.
Prescription Reimbursement Request Form
www.optumrx.comSection A – Pharmacy receipts for reimbursement Use the following checklist to ensure your receipts have all information required for your reimbursement request: Date prescription filled National Drug Code (NDC) number Prescription number (Rx number) Name and address of pharmacy Name of drug and strength Quantity
2021 Prescription Drug List/Formulary PremiumSelectChoice
www.optumrx.comJan 01, 2021 · Drug List/Formulary Effective January 1, 2021 Please read: This document contains information about the drugs . covered under your pharmacy benefit plan. For a complete list of covered drugs or if you have questions: • Call a customer care representative . toll-free at
Covered OTC List - OptumRx
www.optumrx.comhumulin 70/30 kwikpen humulin 70-30 vial humulin n vial humulin r vial novolin r vial novolin 70-30 vial novolin n vial 00169183702 relion novolin 70-30 vial insulin nph hum/reg insulin hm 70-30/ml 10 x x 00169183402 relion novolin n 100 unit/ml insulin nph human isophane 100/ml 10 x x
Clinical Criteria, Step Therapy, and Quantity Limits for ...
www.optumrx.comClinical Criteria, Step Therapy, and Quantity Limits for TennCare Preferred Drug List (PDL) January 1, 2022 . ANALGESICS. Approval of NP agents requires trial and failure, contraindication or intolerance of 2 preferred agents, unless otherwise indicated. Medication PDL Prior Authorization Criteria Qty. Limits PA Form Agents for Opioid Use Disorder
CREDENTIALED PHARMACIES LISTING
www.optumrx.comPlease verify the compound credentialed pharmacy participates in your Plan’s network. 5-10-2021 \ Introduction This user guide will assist members with the selection of a pharmacy which has been credentialed with the OptumRx Network Compound Credentialing Program (NCCP). Using the Guide This guide is in alphabetical order by state.
Your 2021 Comprehensive Formulary - OptumRx
www.optumrx.comPrior Authorization (PA) You or your physician may need to get prior authorization for certain drugs. This means you will need to get approval from OptumRx before you fill your prescriptions. If you do not get approval, the drug may not be covered. Quantity Limits (QL) For certain drugs, there is a limit on the amount of the drug we will cover.
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