Overview
As an OptumRx provider, you know that certain medications require approval, or prior authorization (PA), to ensure that they are medically necessary and appropriate for the reason prescribed before they can be covered. PAs help manage costs, control misuse, and protect patient safety, as well as ensure the best possible therapeutic outcomes.
PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization review decisions on sound clinical evidence and make a determination within the timeframe allowed by state or federal law. To ensure that a PA determination is provided to you in a timely manner, please submit all information needed to make a decision. Lack of information may delay
the decision-making process and may result in a denial unless all required information is received. Once a review is complete, the provider is informed whether the PA request has been approved or denied. If denied, the provider may choose to prescribe a less costly but equally effective, alternative covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision.
OptumRx Prior Authorization Guidelines
The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior authorization (PA) guidelines* to encompass assessment of drug indications, set guideline types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective dates and more. Guidelines are based on written objective pharmaceutical UM decision-making criteria** that are developed from clinical evidence from the following sources:
- Food and Drug Administration (FDA) information
- Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-
analyses, review articles, comparative effectiveness research, evidence-based medicine
reviews, healthcare technology assessments, and pharmacoeconomic and outcomes research - Treatment guidelines, practice parameters, policy statements, consensus statements
created/endorsed by reputable governmental, medical, and/or pharmacy organizations - Pharmaceutical, device, and/or biotech company information
- Medical and pharmacy tertiary resources, including those recognized by CMS
- Relevant and reputable medical and pharmacy textbooks and or websites
*Guidelines are specific to plans utilizing our standard drug lists only. Your patient’s prescription drug benefits may be covered under his/her plan-specific formulary for which these guidelines may not apply. We recommend you speak with your patient regarding prescription drug benefit coverage under his/her health insurance plan or call OptumRx.
** OptumRx’s Senior Medical Director provides ongoing evaluation and quality assessment of the OptumRx UM Program.
How to access the OptumRx PA guidelines:
- Reference the OptumRx electronic prior authorization ePA and fax forms which contain clinical information used to evaluate the PA request as part of the determination process.
- Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed or mailed to you.
- Review PA guideline changes.
OptumRx Prior Authorization and Exception Request Procedures
Submitting an electronic prior authorization (ePA) request to OptumRx
ePA is a secure and easy method for submitting, managing, tracking PAs, step therapy and non-formulary exception requests. It enables a faster turnaround time of coverage determinations for most PA types and reasons.
Login to your preferred web-based portal account and select “New Request”within your Dashboard to submit your PA request.
Submitting a PA request to OptumRx via phone or fax
As part of an ongoing effort to increase security, accuracy, and timeliness of PA requests and determinations, OptumRx is retiring most fax numbers used for submitting pharmacy prior authorization requests for all plans managed by OptumRx, except for the following states: MA, RI, SC, and TX. We strongly
encourage providers to submit PA requests using the ePA process as described above.
If providers are unable to submit electronically, we offer the following options:
- Call 1-800-711-4555 to submit a verbal PA request
- View and print a PA request form
For urgent requests, please call us at 1-800-711-4555.
(Hours: 5am PST to 10pm PST, Monday through Friday.)