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You may also ask us for a coverage determination by phone at 1- 8?

Optum Rx 1-800-711-4555 1-844-403. Additional customer service resources Please complete ALL information below and fax your request to 1-888-671-5285 This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). 3 requires the use of a uniform electronic prior authorization form when a policy, certificate or contract requires prior authorization for prescription drug benefits. 3 6 The information contained in this document is proprietary and confidential to OptumRx. homes for rent in batesville ms State-Specific PA Forms (Non-Medicare, Applies to Optum Rx and UnitedHealthcare): State of Arizona prior authorization form; State of California prior authorization form; State of Colorado prior authorization form and 5) ask whether a prescription drug or device requires prior authorization; or 6) request prior authorization of a health care service. Please refer to wwwcom for medication fax request forms. Prior Authorization Request Form which uses Optum Rx for certain pharmacy benefit services includes requests for benefit coverage beyond plan specifications. Brand-name medications are shown in UPPERCASE (for example, CLOBE) and generic medications in lowercase (for example, clobetasol). This form may be sent to us by mail or fax: Address: Fax Number: Optum Rx Prior Authorization 1-844-403-1028 Mission, KS 66201. mom forced anal This form may be used for non-ur gent requests and faxed to 1-844 -403-1028. 1-844-403-1028 Prior Authorization Department P Box 25183 Santa Ana, CA 92799 You may also ask us for a coverage determination by calling the member services number on the back of your ID card. Find a network pharmacy This form may be sent to us by mail or fax: Address: Fax Number: Optum Rx Prior … Fax: 1-877-342-4596 Mon-Fri; 8:00am-10:00pm EST Sat-Sun; 9:00am-8:00pm EST NPI: … For urgent or expedited requests please call 1-800-711-4555. ; By Fax: Send the PA form to 1-866-434-5523. sams syncrony com: 952-934-8100 Created Date: 11/26/2024 11:05:53 AM Please contact the OptumRx Prior Authorization department at 1-800-711-4555 or. ….

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