UHC – MEDICATION SOURCING EXPANSION PRESCRIBER ORDER FORM: Submit completed form and clinical documentation

UnitedHealthcare Clinical Services and Therapy Request Form

UnitedHealthcare Community Plan Pharmacy prior authorization guidelines for AZ - Preferred Non-Solid Dosage Forms

UnitedHealthcare Community Plan Pharmacy prior authorization guidelines for CA - Preferred Non-Solid Dosage Forms

OAR 836-053-1205: Exhibit 1, Uniform Prior Authorization Prescription Request, form (440-4992)

Prior Authorization Fax Form

Use this paper fax form to submit requests for the following state plans: Virginia Commonwealth Coordinated Care Plus (CCC Plus)

Use this paper fax form to submit requests for the following state plans: Virginia Commonwealth Coordinated Care Plus (CCC Plus)

Use this paper fax form to submit requests for the following state plans: Virginia Commonwealth Coordinated Care Plus (CCC Plus)

Use this paper fax form to submit requests for the following state plans: Washington UnitedHealthcare Community Plan

Use this paper fax form to submit requests for the following state plans: Washington UnitedHealthcare Community Plan

Use this paper fax form to submit requests for the following state plans: Virginia Commonwealth Coordinated Care Plus (CCC Plus)

Use this paper fax form to submit requests for the following state plans: Washington UnitedHealthcare Community Plan

Use this paper fax form to submit requests for the following state plans: Virginia Commonwealth Coordinated Care Plus (CCC Plus)

Use this paper fax form to submit requests for the following state plans: Nebraska UnitedHealthcare Community Plan - Heritage Health

Use this paper fax form to submit requests for the following state plans: Nebraska UnitedHealthcare Community Plan - Heritage Health