Prior Authorization Policy

Prior Authorization Policy

Prior authorization policies are confidential and proprietary. All policies (except those indicated with an asterisk*) are maintained by OptumRx Pharmacy and Therapeutics Committee and are reviewed at least annually for updates.

Drug Prior Authorization Form - (Adcira (tadalafil), Ceprotin, Entyvio, Ilaris, Krystexxa, Kymriah, Luxturna, Nplate, Nulojix, Ocrevus, Radicava, Revatio (sildenafil), Revatio suspension, Revatio injection, Signifor LAR, Soliris, Simponi Aria, Stelara, Sylvant, Xiaflex, Yescarta, Eylea, Lucentis, Viscosupplements, Orencia IV, All Hepatitis C Medications)

Drug Prior Authorization Form - (All Other Drugs)