Prescription Drug Authorization Forms — Employer Plans, Individual & Family Plans, and FAMIS

As of November 1, 2021, drug authorization requests for Individual & Family Plans will be processed and reviewed by Optima Health. Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms.

If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522.

Pharmacy General Exception Forms

• Maximum Daily Dosage Limit Exceptions Request Form
• Orally Administered Oncology Medications
• Pharmacy Medical Necessity Request Form 
• Pancreatic Enzyme Utilization Criteria for Cystic Fibrosis