Coverage Determination Request Form
Request a Coverage Determination
Getting Started
If you would like to request a coverage determination, make an exception to the rules or restrictions on our plan’s coverage of a drug that you are currently taking, or if your provider is planning for you to take a drug restricted by our plan, you may download the Coverage Determination Request Form below and submit it to us via mail or fax.
If you need assistance, you can always contact Pharmacy Member Services at:
1-800-891-6989 (TTY 711)
Download the Coverage Determination Request Form:
Once complete, you can mail the form to:
or call us directly at: 1-800-891-6989
Redetermination of a Medicare Prescription Drug Denial
Request for Redetermination
If you or your provider disagree with a coverage decision made by the plan, you can download and submit the following Request for Redetermination of Medicare Prescription Drug Denial Form.
This is considered an appeal of a coverage determination.
Download the Redetermination of Medicare Prescription Drug Denial Form.
Once complete, you can mail the form to:
OptumRx Prior Authorization Appeals
P.O. Box 2975
Mission, KS 66201
or call us directly at: 1 (888) 403-3398
