Provider Forms and Documents
Now submit important forms online
We've made it faster and easier for providers like you to submit the forms you use most. Now the Prior Authorization Guideline Request form and the Formulary Change Request may be submitted online. Just click the links below to get started. The New Prescription Fax Form is still available below to print and fax.
Documents to submit online:
- Prior Authorization Guideline Change Request Form
Allows you to request a review of prior authorization guidelines. This is not a medication prior authorization request. Please go to the Prior Authorization page for those requests
- Formulary Change Request Form
Allows you to request a review of a formulary.
Documents to download and print:
- Medicare/ Part D Prior Authorization Forms
Allows you to print a drug-specific prior authorization form to complete and fax to OptumRx. Use these forms for non-specialty products such as oral medications and diabetic injectable products. Urgent requests should be submitted via phone at 800-711-4555.
- New Prescription Fax Form
Allows you to submit a new prescription for a patient.
- E-prescribing Overview
- The Benefits of Disease Therapy Management (DTM) for Multiple Sclerosis (MS)
- Factor Prescription Request Form
- State of New Mexico Prior Authorization Form
- Non-Medicare (Commercial) Universal Prior Authorization Form
Use this generic form if you are located in Arkansas, Louisiana or Mississippi or cannot locate an applicable drug-specific form. Urgent requests should be submitted via phone at 800-711-4555.
- Pharmacy Processing Information and Notices
- D.0 Payer Sheet Medicare
- D.0 Payer Sheet Commercial
- D.0 Payer Sheet Raytheon Wrap COB Processing
- D.0 Payer Sheet Partners Rx Coupons
- D.0 Payer Sheet Partners Rx Copay Billing
- Part D 2013 BIN PCN and GROUP Processing Information
Provider Frequently Asked Questions:
You may have specific concerns or special situations that you have questions about. The most common questions we are asked are listed in our Provider Frequently Asked Questions. Please refer to these before contacting first.dba.
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