1. Download an Optum Specialty Pharmacy referral form below
2. Fill out the form
3. Submit to Optum Specialty Pharmacy
Forms
Download neuromuscular disorder referral form
This is an Optum prior authorization criteria specific form to prescribe Botox treatment for migraines, cervical dystonia and overactive bladder:
Download neuromuscular disorder referral form
This is an Optum prior authorization criteria specific form to prescribe Botox treatment for achalasia, chronic anal fissure, detrusor overactivity, spasticity, bleopharospasm:
Complete and return this form to enroll in Revlimid, Pomalyst or Thalomid treatment:
This is an Optum prior authorization criteria specific form to enroll or prescribe RSV and Synagis treatment: