HIV Exemption Program
Patients who are receiving treatment for HIV infection may be able to fill their specialty medications at an in-network pharmacy of their choice.
Am I eligible for an exemption?
Complete and return this form if you do not want to have your HIV treatment related specialty medications shipped to you by Optum Specialty Pharmacy for one or more of the following reasons: privacy concerns, delivery concerns, or you are unable to effectively discuss your condition over the phone due to an HIV-related neurocognitive disorder or the significant HIV-related impairment that is being monitored or treated.
Please complete, sign and date this form, and provide your name, address, telephone number, and member identification number where indicated and submit to OptumRx through one of the below options. Or, you may call us at
Mail: OptumRx, P.O. Box 2508, Mission, KS 66201