Member reimbursement pharmacy form please read the back for instructions. Optumrx medicare prior authorization, quantity limits and formulary exception form. 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. I traveled outside my plans service area and needed my medication but could not access a network pharmacy. You can view drug lists for optima health members by visiting the member website using the links below. Nevada medicaid and nevada check up optumrx request for. It deals with formulary administration, benefit plan design and management, pharmacy. An important part of the pdl is giving you choices so you and your doctor can choose the best course of treatment for you. Optum tier 1 if you need drugs to treat your illness or condition 30 lowcost generics 30day supply retail pharmacy. Im a rn with a specialty physician office and do all the prior authorizations for our specialty medications. Catamaran corporation formerly sxc health solutions is the former name of a company that now operates within unitedhealth groups optumrx division since july 2015.
Call the tollfree member phone number on your health plan id card. 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. Proper consent to disclose phi between these parties has been obtained. 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. Behind every prescription, more than 150,000 people work. Connecting billions of data points, we empower doctors to make informed decisions. The information contained in this document is proprietary and confidential to optumrx. A formulary is a list of prescribed medications chosen by your plan for their safety, cost and effectiveness. Dear name, we wanted to make you aware of a recent incident that may have affected some of your health information. Member and physician information please use black or blue ink. Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement. Please note that most medications on the formulary have a deductible, but preventive medications do not. Fax this form to the plans appeal or authorization department.
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. Locate a participating retail pharmacy by zip code. 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. From forms to formularies, find the information you need. All optum tm trademarks and logos are owned by optum, inc. Medco obtaining an authorization, including specialty drugs. Your 2020 formulary for the most current list of covered medications or if you have questions.
Pdp prescription reimbursement request form use this form to request reimbursement for covered medications purchased at retail cost. Check your benefit plan documents to find out your specific pharmacy plan costs. Your prescription drug list formulary this formulary outlines the most commonly prescribed medications covered under your plans prescription drug benefits. Member id number additional coverage, if applicable secondary member id number last name first name mi delivery address apt. 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. Refer to the cms medicare claims processing manual pdf, 605 kb pub. Financial medicare prior authorization optumrx pdf. Formularies and drug lists providers optima health. This comprehensive formulary is a complete list of the drugs covered by our plan. We realize that this formulary may not include every drug from every manufacturer. As a pharmacy care services company, optumrx goes beyond traditional pharmacy benefit management. Our contact information, along with the date we last updated the formulary, appears on the cover. Jul 1, 2018 a formulary is a list of prescribed medications selected by your plan for their it includes both brand and generic prescription. It includes both brand and generic prescription medications.
Specialty drugs must be purchased from walmart specialty or optum specialty pharmacy. Prescription reimbursement request form use this form to request reimbursement for covered medications purchased at retail cost. This info will allow those at optumrx to determine whether or not partial or full coverage is feasible. This document contains information about commonly prescribed medications. Prescription drug lists and formularies for all optima health plans. Table of contents click on any section or page below to go directly to that portion of the document. Preventive medications are a group of products in your plans formulary which tells you what medications your plan covers. This formulary applies to members of our unitedhealthcare west hmo medical plans with a pharmacy benefit. Our contact information, along with the date we last updated the formulary, is on the cover. This abridged formulary drug list is not a complete list of drugs covered by our plan.
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. Look up possible lowercost medication alternatives. Member reimbursement drug claim form coverage provided by kaiser foundation health plan of washington and kaiser foundation health plan of washingtonoptions, inc.
Premiumvalue formulary reference guide formulary disclaimer. 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. The medications listed on this formulary are subject to change pursuant to the formulary management activities of optum. Free optumrx prior prescription rx authorization form pdf. Optumrx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. All other brand or product names are trademarks or. If the request is for a drug not listed on the ahcccs drug list, the documentation. 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. An optum id securely manages your account so that you can use one optum id and password. Alternatively you can use our online search tool for the most uptodate information. Medicare replacement pdf download medicare benefits pdf download medicare part b pdf download list of formulary drugs optum rx 2019.
If your medication is placed in formulary brand or non formulary levels, look to see if there is a formulary generic option available. To create the list, optumrx is guided by the pharmacy and. The drug list may not include all drugs covered by your prescription drug benefit. The optum premium formulary is a partiallyclosed formulary. Visit your plans member website listed on your id card to. The formulary is also known as the prescription drug list pdl. You should always check the program guide andor policy manual for coverage. Use this universal appeal form to request an appeal if the initial request has been denied.
The following types of individuals may be appointed to act as representative for a party to an appeal. Any person who knowingly presents a false or fraudulent claim for payment or a loss is subject to criminal and civil penalties. Member reimbursement drug claim form complete this form, attach prescription labels and mail to. Medications are listed by categories or classes and are placed into cost levels known as tiers. This document includes a partial list of the drugs formulary for our plan and is current as of august 1, 2015. For a complete, updated formulary drug list, please contact us. Additional information and instructions on back, please read carefully. For an uptodate formulary drug list, please call us. 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. The enhanced, basic and value medicare rx options include a formulary, which is a list of the medications covered under each option. The presence of a medication on this formulary list does not guarantee coverage. If you have any questions regarding this process, please contact optum rx s customer service at 855 5776310.
Medicare replacement pdf download medicare benefits pdf download medicare part b pdf download list of formulary drugs optum rx 2018. The benefit design determines what is covered and the applicable copayment. Claforan suprax fourth generation generic july 2016 cefepime non preferred antiinfectives maxipime fifth generation penicillins non preferred generic teflaro amoxicillin. Prescription prices may vary from pharmacy to pharmacy and are subject to change. We tackle trends and pinpoint solutions for our clients. Existing utilizers of these medications will be allowed to continue on therapy. Complete this form, attach prescription labels and mail to. The health insurance portability and accountability act of 1996 hipaa privacy rule gives you rights over your protected health information phi, including the. When you choose unitedhealthcare with optum rx, youll have access to programs that empower you to make more informed. An incomplete form may either delay your reimbursement or may be returned for additional information. Here you will find important program information, prior authorization forms, clinical criteria and all prescriber communications needed to provide an overall continuity of care.
If your medication is placed in formulary brand or nonformulary levels, look to see if there is a formulary generic option available. For your protection, arizona law requires the following statement to appear on this form. A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. A list of tried and failed medication must be provided as a justification for the request alongside the diagnosis. A major goal as a medicare part d contractor is to ensure that our beneficiaries receive safe, highquality, costeffective medication therapy. Optumrx receives eligibility information from vha occ along with pharmacy information to process claims electronically. If you have any questions regarding this process, please contact optum rxs customer service at 855 5776310.
Confirm you conduct manual eligibility updates at no charge to the state. This document contains information about some of the drugs we cover in this plan. Please complete this form and fax to optum rx at 866 4634838. Your 2018 formulary signaturevalue fourtier this formulary is accurate as of january 2018 and is subject to change after this date. Copayments for tiers 1, 2 and 3, are listed next to rx copay on the ship membership card. Visit your plans website on your member id card to. Exhibit 121 optumrx prior authorization request form ahcccs. Arizona health care cost containment system ahcccs. Generally, if you are taking a drug on the 2015 drug list that was 2015 quick reference guide optum medical network. Grandfathering will not be provided for any other excluded drugs. Search the list of fdaapproved drugs and coverage for each by entering a drug name below. Your 2015 formulary signaturevalue effective july 1, 2015 please read. Optumrx agrees to grandfather the statezs current formulary for the. Most other prescription drugs are on the formulary including specialty medications.
It includes both brand and generic prescription medications approved by the u. 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. I would give optum rx a 0 if i could, but since i cant i will give them a 1. Rx id found under your name on the card is your member id. Member costsharing for specialty drugs is detailed in the online ship plan document. The information in this document is for the sole use of optumrx. Be sure to show your harvard pilgrim optum rx card at the pharmacy to ensure you pay the correct cost sharing amounts. 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. Formulary generic medications are your lowestcost options. 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. I travel 2000 miles between homes, multiple times each year, and recently lost one of my maintenance prescriptions.
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