Specialty Pharmacy Referral & Enrollment Forms

1. Download an Optum Specialty Pharmacy referral form below
2. Fill out the form
3. Submit to Optum Specialty Pharmacy

Forms

Download dermatology referral form

Download fertility referral form

Download third-party/donor fertility referral form

Download gastroenterology referral form

Download general referral form

Download Hepatitis C referral form

Download immune globulin therapy referral form

Download multiple sclerosis referral form

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

Download oncology referral form

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

Download oncology REMS referral form

Download opioid antagonist referral form

Download osteoporosis referral form

Download pulmonary arterial hypertension referral form

Download rheumatology referral form

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

Download Synagis referral form

Specialty pharmacy referral and enrollment forms

Forms

Dermatology referral form

Fertility referral forms

Gastroenterology referral form

General referral form

Hepatitis C referral form

Immune globulin therapy referral form

Multiple sclerosis referral form

Neuromuscular disorder referral forms

Oncology referral form

Oncology REMS referral form

Opioid antagonist referral form

Osteoporosis referral form

Pulmonary arterial hypertension referral form

Rheumatology referral form

Synagis referral form