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 - (Ceprotin, Entyvio, Ilaris, Krystexxa, Kymriah, Luxturna, Nplate, Nulojix, Ocrevus, Radicava, 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)