Optum Rx Prior Authorization Request Form (General)

Optum Rx uses this two-page fax form for drug prior authorization for commercial and Medicare Part D members when no drug-specific or state form applies. Optum Rx steers prescribers to electronic PA first, and this form is the fallback when ePA or a phone request isn't possible. It asks for the diagnosis, prior medications, contraindications, labs and any quantity-limit justification, and page 2 warns that a request may be denied unless all required information is received.

Who completes it

The prescriber or the prescriber's office completes the four required blocks (member, provider, medication and clinical information), any quantity-limit questions and the attestation. The form records the name of the person completing it separately from the prescriber's signature.

How to fill it in

Member Information (required)

Enter the member's name, insurance ID number, date of birth, street address, city, state, ZIP code and phone. Every block on page 1 except the quantity-limit questions is labeled required, and page 2 warns that a request may be denied unless all required information is received, so complete each line rather than leaving details to attached records.

Provider Information (required)

Give the provider's name, NPI number, specialty, office phone, office fax and office street address with city, state and ZIP. The banner above this block points to ProviderPA.com for electronic submission. Optum Rx's ePA page says electronic requests support all forms of PA and formulary exception requests, so the paper form is the fallback when ePA or phone isn't possible.

Medication Information (required)

Write the medication name, dosage form and strength, and the directions for use. Check the box if the request is for the brand product, and check the continuation-of-therapy box when the patient is already taking the drug. These two boxes tell the reviewer whether the request is a brand request, a renewal or a new start.

Clinical Information (required)

Give the diagnosis for the requested drug and its ICD-10 codes. List ALL medications and strengths tried with an inadequate response, with the length of each trial and the reason for stopping. Then list every medication the patient has a contraindication or intolerance to, with the specific issue for each. Finish with any supporting labs or test results, specifying which ones.

Quantity limit requests

Complete this block only for a quantity exception. State the quantity requested per day and check the reason for exceeding plan limits: titration or loading dose, a dose-alternating schedule, a strength not commercially available, a medical justification for not using a higher available strength at the same frequency, a larger surface area for topicals, or other. Acetaminophen over 4 grams a day for travel or a stolen supply is a pharmacy override instead.

Prescriber attestation

Answer Yes or No to the attestation that the information is true and accurate to the best of the prescriber's knowledge, and that Optum Rx may perform a routine audit and request the medical information needed to verify it. Print the name of the person completing the form; the prescriber then signs and dates it.

Page 2: other comments and submission notes

Use the open lines for other comments, diagnoses, symptoms, medications tried or failed, or anything else the physician considers important to the review. The page then repeats the rules: no buy and bill drugs, possible denial without all required information, a phone line for patients who cannot meet standard requirements and for urgent requests, and fax for non-urgent requests only.

Common mistakes

Reusing a saved or photocopied form, when the form is barcoded and marked do not copy for future use because Optum Rx updates forms frequently.
Leaving a required block incomplete; page 2 states that the request may be denied unless all required information is received.
Listing prior drugs without the strength, the length of trial and the reason for discontinuation, all of which the clinical section asks for each medication.
Faxing an urgent or expedited request, when Optum Rx asks for those by phone and limits the fax form to non-urgent requests.
Submitting a buy and bill drug supplied by the physician's office, which Optum Rx says it is not authorized to review.
Requesting prior authorization for acetaminophen above 4 grams a day due to travel or a stolen supply, when the pharmacy should call for a one-time override.

Submitting and payment

How to submit it: Fax non-urgent requests to the number on page 2, and call the Optum Rx prior authorization line for urgent or expedited requests. Optum Rx prefers ePA through ProviderPA.com or portals such as CoverMyMeds and Surescripts, which it says return decisions 2 to 3 times faster than phone or fax.
Who pays: The form covers the pharmacy benefit only: Optum Rx is not authorized to review buy and bill drugs supplied by the physician's office, which go through the patient's medical benefit.

Good to know

The form is barcoded and marked do not copy for future use because Optum Rx updates its forms frequently, so download a fresh copy for each request.
When a patient exceeds 4 grams of acetaminophen a day for reasons such as travel or a stolen supply, the pharmacy calls the Optum Rx Pharmacy Helpdesk for a one-time override instead.
Optum Rx publishes drug-specific prior authorization guidelines setting indications, approval criteria and approval duration; call its prior authorization line to have them faxed or mailed.
UnitedHealthcare members have a separate UHC-branded general form, and Medicare Part B versus Part D questions use the Medicare Administrative Coverage Determination Request Form.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization Request Form

Official page PDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Can I fax an urgent Optum Rx prior authorization?

No. Page 2 says urgent or expedited requests should be called in to the Optum Rx prior authorization line, and that the fax form is for non-urgent requests. Electronic PA is the faster alternative: Optum Rx says many ePA determinations arrive within minutes of submission, and chart notes can be uploaded as JPEG, TIFF or PDF.

Can I use the Optum Rx form for a drug given in my office?

No. Page 2 says the request is not for a buy and bill drug and that Optum Rx is not authorized to review medications supplied by the physician's office. For those drugs, contact the patient's medical benefit, which handles its own coverage review.

Does the Optum Rx general form cover quantity limit exceptions?

Yes. The Quantity limit requests block asks for the quantity per day and the reason for exceeding plan limits: titration or loading dose, a dose-alternating schedule, a strength that is not commercially available, a medical reason a higher available strength can't be used, a larger surface area for topicals, or another reason you specify.

What if an Optum Rx prior authorization is denied?

Optum Rx invites prescribers to call its prior authorization line to discuss a denial decision. Page 2 also says to call that line if the patient cannot meet the standard prior authorization requirements. Drug-specific guidelines can be requested by phone and faxed or mailed, which shows what documentation the criteria expect.