2024 Forms

2024 Abridged Formulary-08/25/23

2024 Comprehensive Formulary - 12/1/24

2024 Optum OTC Flyer- How to use your Over The Counter Benefits

2024 LIS Premium Summary Table

2024 Prescription Drug Coverage Determinations, Grievances or Appeals Information

2024 Step Therapy Criteria -   11/1/24

2024 Step Therapy Criteria - Effective 12/1/24

2024 Tier 1 Medications

2024 Prior Authorization Criteria - 11/1/24

2024 Prior Authorization Criteria - Effective 12/1/24

Medicare Part D Coverage Determination Form (for use by Enrollees and Providers)-Updated 9/26/2022

Request for Redetermination of Medicare Prescription Drug Denial

• Access Request Form
• Account Request Form
• Amendment Request Form
• Appeal Request Form
• Confidential Communication Request Form
• Designation of Representative

If a beneficiary would like to appoint a person to discuss or share account information, please complete this form and this request is good for 30 months.

• EFT Form

• How to Appoint a Representative

If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf for a single event, the beneficiary and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. Please return the completed form to: ATTN: Privacy Coordinator, PO Box 6029, Canton, OH 44706.

• How to Find a Provider Using Our Provider Directory
• List of Services That Require Prior Authorization
• UM Internal Coverage Criteria
• PrimeTime Health Plan Pre-Authorization and Referral Form -Updated 8/14/2023
• Medical Care, Services and Payment
• Member Request to Restrict Uses and Disclosures of PHI Restriction Request Form 
• Notice of Privacy Practices
• 2024 Over-The-Counter (OTC) Brochure
• Optum Home Delivery FAQ
• Optum Home Deliver Request form - PDF
• Physician and Hospital Validation
• Waiver of Liability Practices