Drug Authorization Forms

These drug authorization forms are intended for our employer group plans and/or FAMIS members.

If you need drug authorization forms for Individual & Family Plans (OptimaFit), Medicaid Plans, or Optima Medicare HMO please refer to the pages listed below for the proper forms.

Individual & Family Plans (OptimaFit)
Medicaid Plans (Optima Family Care and Optima Health Community Care)
Medicare Plans (Optima Medicare HMO and Optima Community Complete)

Pharmacy General Exception Forms

Maximum Daily Dosage Limit Exceptions Request Form
Pharmacy Medical Necessity Request Form
Pancreatic Enzyme Utilization Criteria for Cystic Fibrosis
Non-Formulary Exceptions Request

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Drug Authorization Forms

Pharmacy General Exception Forms

Drug Authorization Forms