Optima Health
Pharmacy Prior Authorization Request

This pre-authorization form allows members to initiate a request for a non-formulary medication.

The pharmacy department will review your request and process.

The following criteria will be used when reviewing a request:

  • The member has failed a trial of preferred and standard medications.
    These medications should include:
    • Drugs in the same therapeutic class as the requested drug
    • Other recognized drug therapies for the medical condition
  • Drugs on the preferred and standard list are contraindicated for this member.
Patient Name: *
Member Number: *
Drug and Dose: *
Anticipated Length of Therapy: *
Reason For Request: *
Diagnosis: *
Therapies Tried: *
Physician Name: *
Physician Phone:
Physician Fax: