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Specialty pharmacy referral and enrollment forms

Find forms to enroll or prescribe treatment from Optum Specialty Pharmacy. 

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: 

Download neuromuscular disorder referral form

Complete and return this form to enroll in Revlimid, Pomalyst or Thalomid treatment:

Download oncology REMS referral form 

This is an Optum prior authorization criteria specific form to enroll or prescribe RSV and Synagis treatment: 

Download Synagis referral form