Pharmacy Requests

Prior authorization is necessary to ensure benefit payment.

Your provider may prescribe a medication that requires review and approval. This process is called prior authorization, and the goal is to ensure you receive the most appropriate, medically necessary care. If your medication requires prior authorization, is not on the formulary, or is coming up at your pharmacy as not covered, your provider will need to request prior authorization.

Submit a prior authorization online, by fax or mail.

• Fill out a prior authorization request formopens in a new windowopens in a new tab and submit it online.
• Be sure to include the following information or the request will be returned.
  • Requested drug name
  • Strength
  • Quantity
  • Duration of treatment
  • Diagnosis
  • Medical records (chart notes documenting prior therapy), allergies, lab results, etc.
  • Clinical rationale (why covered or preferred drugs may not be appropriate)
• Fax your prior authorization request formopens in a new windowopens in a new tab to 1-800-997-9672.
• Mail it to Sierra Health and Life, Pharmacy Services, Attn: Medical Necessity, P.O. Box 15645, Las Vegas, NV 89114-5645.   

How to file an appeal

All requests requiring a medical or clinical decision are reviewed by a licensed physician or under the supervision of one. Furthermore, only a physician may deny a request. You or your provider may file an appeal if coverage is denied. To appeal a decision, mail a written request within 180 days from the date of the denial to: Sierra Health and Life, 2720 North Tenaya Way, P.O. Box 14865, NV017-3020, Las Vegas, NV 89114-4865.

To check the status of a prior authorization, sign in to the online member center or download the MySHL app. If you have any questions, please contact Member Services toll-free at 1-800-777-1840, TTY 711, Monday through Friday, 8 a.m. to 5 p.m.  

Request reimbursement for covered medications purchased at retail cost.

Fill out the OptumRx prescription reimbursement request formopens in a new windowopens in a new tab. Complete one form per member.

When submitting the form include the original pharmacy receipt for each medication (not the register receipt). If you do not have pharmacy receipts, ask your pharmacy to provide them to you. Pharmacy receipts must contain the following information:

• Date prescription filled
• National Drug Code (NDC) number
• Prescription number (Rx number)
• Name and address of pharmacy
• Name of drug and strength
• Quantity
• Prescribing physician name or ID number

Read the Acknowledgement (section 5) on the front of the form carefully. Then sign and date. Print page 2 of this form on the back of page 1. Send completed form with pharmacy receipt(s) to OptumRx Claims Department, P.O. Box 650334, Dallas TX 75265-0334.

Please note: Cash and credit card receipts are not proof of purchase. Incomplete forms may be returned and delay reimbursement. Reimbursement is not guaranteed. Claims are subject to your plan’s limits, exclusions and provisions.