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Oncology Phone: 877-445-6874 Fax: 877-342-4596 Specialty Pharmacy Enrollment Form Please detach before submitting to a pharmacy – tear here. Oncology Enrollment Form This form is not a valid prescription in Arizona PATIENT INFORMATION Please complete the following or send patient demographic sheet Patient Name Address Address 2 City, State, ZIP 1-877-342-4596 Call 1-877-445-6874 Ready to prescribe? Just e-prescribe, fax or call in your patient’s prescription to Optum® Specialty Pharmacy. We’ll handle the rest. Once …
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1-877-342-4596 Call 1-877-445-6874 Ready to prescribe? Just e-prescribe, fax or call in your patient’s prescription to Optum® Specialty Pharmacy. We’ll handle the rest. Once we receive the prescription, we will: • Complete a benefits investigation and prior authorization • Aid patients in obtaining financial assistance programs
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