Provider Forms and Documents
Now submit important forms online
We've made it faster and easier for providers like you to submit the forms you use most. Now the Prior Authorization Guideline Request form and the Formulary Change Request may be submitted online. Just click the links below to get started. The New Prescription Fax Form is still available below to print and fax.
Documents to download and print:
- Prior Authorization Forms
Allows you to print a drug-specific or universal prior authorization form to complete and fax to OptumRx.
- New Prescription Fax Form
Allows you to submit a new prescription for a patient.
- E-prescribing Overview
- The Benefits of Disease Therapy Management (DTM) for Multiple Sclerosis (MS)
- Factor Prescription Request Form
Documents to submit online:
- Prior Authorization Guideline Change Request Form
Allows you to request a review of prior authorization guidelines. This is not a medication prior authorization request. Please go to the Prior Authorization page for those requests
- Formulary Change Request Form
Allows you to request a review of a formulary.
Pharmacy Processing Information and Notices
- D.0 Payer Sheet Medicare
- D.0 Payer Sheet Commercial
- D.0 Payer Sheet Raytheon Wrap COB Processing
- Part D 2015 BIN PCN and GROUP processing
- D 0 Payer Sheet Commercial UHC
Pharmacy Appeals Guidelines and Forms:
- MAC Appeals Form
- OptumRx MAC Appeal Submission Guidelines and FAQ
- Allows you to download a form for submitting multiple appeals via e-mail.
Provider Frequently Asked Questions:
You may have specific concerns or special situations that you have questions about. The most common questions we are asked are listed in our Provider Frequently Asked Questions. Please refer to these before contacting first.dba.
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