Our contact information, along with the date we last updated the formulary, is on the cover. If the request is for a drug not listed on the ahcccs drug list, the documentation. Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement. Adobe pdf the optumrx prior authorization request form is a simple form to be filled out by the prescriber that requests that a certain treatment or medication be covered for a patient. This form should be used when a drugspecific form is not available.
An optum id securely manages your account so that you can use one optum id and password. Our contact information, along with the date we last updated the formulary, appears on the cover. Catamaran corporation formerly sxc health solutions is the former name of a company that now operates within unitedhealth groups optumrx division since july 2015. Use this universal appeal form to request an appeal if the initial request has been denied. Visit your plans member website listed on your id card to. Coverage for some drugs may be limited to specific dosage forms andor strengths. A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers.
However, you can provide access to the medications your patients need to stay healthy, at a cost that is more affordable, when you choose a generic or preferred drug as appropriate. Member and physician information please use black or blue ink. You should always check the program guide andor policy manual for coverage. New prescription mailin order form 1 member and physician. The health insurance portability and accountability act of 1996 hipaa privacy rule gives you rights over your protected health information phi, including the. Member costsharing for specialty drugs is detailed in the online ship plan document. The benefit design determines what is covered and the applicable copayment.
All optum tm trademarks and logos are owned by optum, inc. Search the list of fdaapproved drugs and coverage for each by entering a drug name below. Prescription prices may vary from pharmacy to pharmacy and are subject to change. Grandfathering will not be provided for any other excluded drugs. Member reimbursement drug claim form coverage provided by kaiser foundation health plan of washington and kaiser foundation health plan of washingtonoptions, inc. Copayments for tiers 1, 2 and 3, are listed next to rx copay on the ship membership card. On march 22, 2016, we were notified that an unencrypted laptop computer.
Behind every prescription, more than 150,000 people work. Your 2019 formulary for the most current list of covered medications or if you have questions. You can view drug lists for optima health members by visiting the member website using the links below. An incomplete form may either delay your reimbursement or may be returned for additional information. This document contains information about commonly prescribed medications. Your 2015 formulary signaturevalue effective july 1, 2015 please read. The premium formulary is considered partiallyclosed because it excludes coverage of some brandname drugs that do not offer a clear clinical advantage over other less costly brand or generic alternatives.
Medications are listed by categories or classes and are placed into cost levels known as tiers. The presence of a medication on this formulary list does not guarantee coverage. This document contains information about some of the drugs we cover in this plan. The enhanced, basic and value medicare rx options include a formulary, which is a list of the medications covered under each option.
Please note that most medications on the formulary have a deductible, but preventive medications do not. Medicare replacement pdf download medicare benefits pdf download medicare part b pdf download list of formulary drugs optum rx 2019. The optum premium formulary is a partiallyclosed formulary. Alternatively you can use our online search tool for the most uptodate information. From forms to formularies, find the information you need. Optumrx agrees to grandfather the statezs current formulary for the. Proper consent to disclose phi between these parties has been obtained. Jul 1, 2018 a formulary is a list of prescribed medications selected by your plan for their it includes both brand and generic prescription.
Preventive medications are a group of products in your plans formulary which tells you what medications your plan covers. This document contains information about the drugs covered under your pharmacy bene t plan. Claforan suprax fourth generation generic july 2016 cefepime non preferred antiinfectives maxipime fifth generation penicillins non preferred generic teflaro amoxicillin. This abridged formulary drug list is not a complete list of drugs covered by our plan. Your prescription drug list formulary this formulary outlines the most commonly prescribed medications covered under your plans prescription drug benefits.
Remove all ranitidine products zantac if you have a prescription for a ranitidine drug zantac, stop taking it and contact your prescriber for an alternative. The comprehensive formulary aarp medicarecomplete plans 3 drug list a formulary drug list is a list of covered drugs selected by your plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Fax this form to the plans appeal or authorization department. We realize that this formulary may not include every drug from every manufacturer.
Your 2020 formulary for the most current list of covered medications or if you have questions. Be sure to show your harvard pilgrim optum rx card at the pharmacy to ensure you pay the correct cost sharing amounts. The information contained in this document is proprietary and confidential to optumrx. I travel 2000 miles between homes, multiple times each year, and recently lost one of my maintenance prescriptions. This formulary applies to members of our unitedhealthcare west hmo medical plans with a pharmacy benefit.
Member reimbursement drug claim form complete this form, attach prescription labels and mail to. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. It deals with formulary administration, benefit plan design and management, pharmacy. Im a rn with a specialty physician office and do all the prior authorizations for our specialty medications. Formularies and drug lists providers optima health. If you have any questions regarding this process, please contact optum rx s customer service at 855 5776310.
The drug list may not include all drugs covered by your prescription drug benefit. A major goal as a medicare part d contractor is to ensure that our beneficiaries receive safe, highquality, costeffective medication therapy. For an uptodate formulary drug list, please call us. Here you will find important program information, prior authorization forms, clinical criteria and all prescriber communications needed to provide an overall continuity of care. A formulary is a list of prescribed medications chosen by your plan for their safety, cost and effectiveness. Optumrx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. Aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf download medicare benefits pdf download medicare supplemental insurance pdf download medicare coverage pdf download medicare supplement plans pdf download aarp life insurance pdf download. Member id number additional coverage, if applicable secondary member id number last name first name mi delivery address apt. Enhanced medicare rx option pdf 39k basic medicare rx option pdf 39k value medicare rx option pdf 38k sidebyside comparison of all three plans pdf 33k the health options program formulary. Complete this form, attach prescription labels and mail to.
I traveled outside my plans service area and needed my medication but could not access a network pharmacy. Exhibit 121 optumrx prior authorization request form ahcccs. This info will allow those at optumrx to determine whether or not partial or full coverage is feasible. Most other prescription drugs are on the formulary including specialty medications. The information in this document is for the sole use of optumrx. I would give optum rx a 0 if i could, but since i cant i will give them a 1. Formulary generic medications are your lowestcost options. Any person who knowingly presents a false or fraudulent claim for payment or a loss is subject to criminal and civil penalties.
Jan 12, 2017 optum rx united health prescription solutions optum rx is practice medicine without a license, breaching their contract, using bait and switch, raising rates with no regulations. Rx id found under your name on the card is your member id. To create the list, optumrx is guided by the pharmacy and. The optumrx prior authorization request form is a simple form to be filled out by the prescriber that requests that a certain treatment or medication be covered for a patient. Optumrx medicare prior authorization, quantity limits and formulary exception form. Additional information and instructions on back, please read carefully.
Premium formulary drug list cefaclor nallpendextrose cephalexin penicillin g potassium in isoosmotic the optum drug list is a guide identifying generic, preferred brand name, and nonpreferred brand name medicines within select therapeutic categories. If you have any questions regarding this process, please contact optum rxs customer service at 855 5776310. Your formulary this formulary outlines the most commonly prescribed medications from your plans complete pharmacy benefit coverage list, also known as a prescription drug list pdl. As a pharmacy care services company, optumrx goes beyond traditional pharmacy benefit management. Optumrx receives eligibility information from vha occ along with pharmacy information to process claims electronically. A list of tried and failed medication must be provided as a justification for the request alongside the diagnosis. As the main caregiver of our members health, optumrx is excited to partner with you on educating and providing care for our members. Member reimbursement drug claim form complete this form. The medications listed on this formulary are subject to change pursuant to the formulary management activities of optum. Please complete this form and fax to optum rx at 866 4634838. Connecting billions of data points, we empower doctors to make informed decisions. Your 2018 formulary signaturevalue fourtier this formulary is accurate as of january 2018 and is subject to change after this date. Locate a participating retail pharmacy by zip code. Check your benefit plan documents to find out your specific pharmacy plan costs.
An important part of the pdl is giving you choices so you and your doctor can choose the best course of treatment for you. This document includes a partial list of the drugs formulary for our plan and is current as of august 1, 2015. If your medication is placed in formulary brand or nonformulary levels, look to see if there is a formulary generic option available. It includes both brand and generic prescription medications. Specialty drugs must be purchased from walmart specialty or optum specialty pharmacy. Financial medicare prior authorization optumrx pdf. The formulary is also known as the prescription drug list pdl.
Medicare replacement pdf download medicare benefits pdf download medicare part b pdf download list of formulary drugs optum rx 2018. Prescription drug lists and formularies for all optima health plans. The following types of individuals may be appointed to act as representative for a party to an appeal. We tackle trends and pinpoint solutions for our clients. Oct 14, 2015 document includes a complete list of the drugs formulary for our plan drug list outside of regular or necessary updates, members may receive a special mailing. For your protection, arizona law requires the following statement to appear on this form. All other brand or product names are trademarks or. Existing utilizers of these medications will be allowed to continue on therapy. Confirm you conduct manual eligibility updates at no charge to the state. Look up possible lowercost medication alternatives.
Visit your plans website on your member id card to. Arizona health care cost containment system ahcccs. Pdp prescription reimbursement request form use this form to request reimbursement for covered medications purchased at retail cost. The pricing estimates given are based on the most recent information available and may change based on when you actually fill your prescription at the pharmacy. Refer to the cms medicare claims processing manual pdf, 605 kb pub. Prescription reimbursement request form use this form to request reimbursement for covered medications purchased at retail cost. Nevada medicaid and nevada check up optumrx request for. Call the tollfree member phone number on your health plan id card.
Member reimbursement pharmacy form please read the back for instructions. It includes both brand and generic prescription medications approved by the u. Table of contents click on any section or page below to go directly to that portion of the document. Free optumrx prior prescription rx authorization form pdf. Generally, if you are taking a drug on the 2015 drug list that was 2015 quick reference guide optum medical network. Premiumvalue formulary reference guide formulary disclaimer. This comprehensive formulary is a complete list of the drugs covered by our plan. For a complete, updated formulary drug list, please contact us. Medco obtaining an authorization, including specialty drugs. If your medication is placed in formulary brand or non formulary levels, look to see if there is a formulary generic option available. M e m b e r r e im b u r s e m e n t d r u g c l a im f o r m complete this form, attach prescription labels and mail to. When you choose unitedhealthcare with optum rx, youll have access to programs that empower you to make more informed. Dear name, we wanted to make you aware of a recent incident that may have affected some of your health information.
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