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(1) dosage form(s) and/or dosage(s) tried; (2) explain medical reason] ☐ request for formulary tier. Do not copy for future use. Box 25183 santa ana, ca 92799.
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Web optum is streamlining our provider notification process when patients request authorization for a prescription. Web to submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., hcr), please contact the optumrx® pa department through telephone. Web this form may be sent to us by mail or fax: This is how it works.
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