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.
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.
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:
Read the Acknowledgement (section 4) 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 650540, Dallas TX 75264-0540.
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.