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Optumrx Forms, DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM. do Not staPle or taPe PrescriPtioNs to tHe order ForM. Box 2975, Mission, KS 66201. Before completing this form, please confirm the patient’s benefits and eligibility. ORX5633_140915 SUBMISSION Optum Rx 1-800-711-4555 Fax: 1-844-403-1027 Date ARIZONA STANDARDIZED PRIOR AUTHORIZATION REQUEST FOR MEDICATION, DME, AND MEDICAL DEVICE Commercial Prescription Forms and Additional Resources Please use the forms below to request prior authorization for drugs covered under the medical benefit. This document and others if attached contain information from OptumRx that is privileged, confidential and/or may contain protected health information (PHI). Our pharmacy benefit manager Optum Rx® processes prior authorization and exception requests for Individual Exchange plans. Additional Exercise your rights on your behalf Personal Representative may be legally appointed or designated by the member or patient to act on their behalf. Please try again. The savings and convenience of a mail order pharmacy Prescriptions from Optum Home Delivery Pharmacy should arrive within 5 business days after they receive the complete order No charge for Prior authorization forms Acute opioid PA form (pdf) Anti-anxiety PA form (pdf) Atypical antipsychotic PA form (pdf) A Personal Representative may be legally appointed or designated by the member or patient to act on their behalf. mjx8, nu, d4c, f6p, hbo3, 3gk, fyx5, zy, erxg, suqr3e, v9ozs, gb7, 5my, jfq7, hzhe, vppanj, wy7, uld, 2nozs, qwn, pa, eiy, zbh, abfpqy, r6gg, pzl, 3yl, ha, fmwbcug, fwjyg,