Enrollment Forms

Download Enrollment Forms

Crohn's/Ulcerative Colitis
Cystic Fibrosis
Dermatology
Enzyme Replacement Therapy
General Enrollment
Growth Hormone
Hematopoietic
Hemophilia
Hepatitis C
Hepatitis C Digital Proteus Program
Immune Globulin Therapy
Infertility (General)*
Makena
Multiple Sclerosis
Neuromuscular Therapy
Oncology

For medications not listed on this form, please refer to our partners at 

for additional limited distribution products.

Oncology-Revlimid, Pomalyst, Thalomid
Ophthalmology
Osteoarthritis
Osteoporosis
Pulmonary Arterial Hypertension
Rheumatology
RSV Regular Referral
Sublocade
Transplant

Optum Prior Authorization Criteria Specific Forms

Injectable Psychotropic - Optum
Neuromuscular - Optum - Achalasia, Chronic Anal Fissure, Detrusor Overactivity, Spasticity, Bleopharospasm
Neuromuscular - Optum - Migraine, Cervical Dystonia, Overactive Bladder
RSV- Optum