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Enrollment Forms

Download Enrollment Forms

Crohn's/Ulcerative Colitis
Cystic Fibrosis
Enzyme Replacement Therapy
General Enrollment
Growth Hormone
Hematopoietic
Immune Globulin Therapy
Infertility (General)*
Multiple Sclerosis
Neuromuscular Therapy
Oncology

For medications not listed on this form, please refer to our partners at Avella Specialty Pharmacy for additional limited distribution products.

Oncology-Revlimid, Pomalyst, Thalomid
Ophthalmology
Osteoarthritis
Pulmonary Arterial Hypertension
RSV Regular Referral

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