HIV/AIDS Specialty Medications Exemption Form
If you are taking specialty medications as part of your HIV treatment regimen, you may be eligible for an exemption to using
BriovaRx
®
, the OptumRx
®
specialty pharmacy. Specialty medications which may be eligible for this exemption include all
medications used to treat HIV infection and medications used in combination with HIV treatment. Please check the applicable
box[es] below, sign and date this form, and provide your name, address, telephone number, and member identification number
where indicated and return to OptumRx. Or, you may call us at 1-866-803-8570.
Mail: OptumRx, P.O. Box 2508, Mission, KS 66201
Fax: 1-855-873-2378
¨
I am concerned about my privacy in connection with receiving medication packages where I live or work.
¨
I am concerned about the timing, accuracy or other problems with the delivery of my medications from BriovaRx.
¨
I am unable to effectively discuss my condition over the phone with BriovaRx due to an HIV-related neurocognitive disorder
or other significant HIV-related impairment that is being monitored or treated.
If you checked any of the boxes above, please identify the network pharmacy where you want to get your eligible
specialty medications and complete the information below. This will be the specific retail pharmacy you will use to pick up
your eligible medication(s). (Note: You may contact us at any time with the name of a different network pharmacy that you want to
use for your eligible specialty medications.)
PLEASE PRINT
Member Name: _____________________________________________________________________________________________
Member Address: ___________________________________________________________________________________________
Member Phone Number: ______________________________________________________________________________________
Member ID: ________________________________________________________________________________________________
Date of Birth: _______________________________________________________________________________________________
Pharmacy Name: ____________________________________________________________________________________________
Pharmacy Address: __________________________________________________________________________________________
Pharmacy Phone Number: ____________________________________________________________________________________
______________________________________________________________________________ _______________________
Signature Date
OPTIONAL – Please help us serve you better
If you checked any of the boxes above, please explain your concerns: ________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
M54250-A 8/17 © 2017 Optum. All Rights Reserved.
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