Optumrx tier cost sharing request form 2026

1. Click ‘Get Form’ to open the optumrx tier cost sharing request form in the editor.
2. Begin by filling out the 'Member Information' section. Enter the member's name, insurance ID number, and date of birth. Ensure all fields are completed accurately.
3. Next, provide 'Provider Information'. Input the provider's name, NPI number, office phone, and address details. This information is crucial for processing your request.
4. In the 'Medication Information' section, specify the medication name and strength. Indicate if you are requesting a brand medication or if this is a continuation of therapy.
5. Complete the 'Clinical Information' by detailing the patient's diagnosis and any previous medications tried. Include ICD-9/10 codes where applicable.
6. Lastly, review all sections for completeness before submitting your form. Missing information may lead to denial of your request.

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