Enrollment Forms

Download Enrollment Forms

Crohn's/Ulcerative Colitis
Enzyme Replacement Therapy
Hepatitis C

Click Hepatitis C Digital Proteus Program to obtain the enrollment form.

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
Pulmonary Arterial Hypertension

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