Please note: All information below is required to process this request
Mon-Fri: 5am to10pm Pacific / Sat: 6am to 3pm Pacific
For real time submission 24/7 visit www.OptumRx.com and click Health Care Professionals
OptumRx • M/S CA 106-0286 • 3515 Harbor Blvd. • Costa Mesa, CA 92626
®
Wellbutrin SR® & Wellbutrin XL Prior Authorization Request Form
DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED
Member Information (required)
Provider Information (required)
Member Name:
Provider Name:
Insurance ID#:
NPI#:
Date of Birth:
Office Phone:
Street Address:
Office Fax:
City:
State:
Phone:
Zip:
Specialty:
Office Street Address:
City:
State:
Zip:
Medication Information (required)
Medication Name:
Strength:
Dosage Form:
 Check if requesting brand
Directions for Use:
 Yes  No Continuation of therapy? If “YES”, answer the following:
 Yes  No Has member been on this medication in the last 180 days?*
 Yes  No Does the prescriber confirm that the medication has been
effective in treating the member’s medical condition?*
Clinical Information
(required)
Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses OptumRx for certain pharmacy benefit services. Your patient’s
benefit plan requires that we review certain requests for coverage with the prescribing physician. This includes requests for benefit coverage beyond plan
specifications. Please complete the following questions and then fax this form to the toll free number listed below. Upon receipt of the completed form,
prescription benefit coverage will be determined based on the benefit plan’s rules.
Select the requested drug:  Wellbutrin SR  Wellbutrin XL
Medication history*:
 Yes  No Does the member have a history ≥ 4 weeks of trial of the therapeutically equivalent generic? If yes, please document the date
and duration of trial:
Date: ____________________________ Duration of trial: __________________________________________________
 Yes  No Does the member have a documented history of intolerance to the therapeutically equivalent generic which is unable to be
resolved with attempts to minimize the adverse effects where appropriate (e.g. take with food to minimize nausea, take prior to
bedtime to manage fatigue, take in the morning to manage insomnia, eat high-fiber diet with plenty of water to minimize
constipation, etc.)?
 Yes  No Will medical records documenting the adverse effect/inadequate response to the therapeutically equivalent generic be
®
submitted to OptumRx with this form?
**Please note: Chart documentation of the above is required to be submitted along with this fax for brand Wellbutrin SR and Wellbutrin XL
 Yes  No Does the member have a history of at least 4 weeks of therapy with, contraindication to, or intolerance to one generic
antidepressant (bupropion IR/SR/XL, citalopram, escitalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline,
venlafaxine, venlafaxine ER capsules)?
If yes, please document the name of the medication and date:
Medication:______________________________________________
Date: ___________________________________
 Yes  No Was the requested medication initiated during a recent inpatient mental health hospitalization, and the member is stabilized on
the requested medication?
 Yes  No Is the member new to UnitedHealthcare Insurance and currently stabilized on the requested medication?
For brand Wellbutrin SR requests, also answer the following*:
 Yes  No Does the member have a history of failure, contraindication, or intolerance to bupropion extended-release (generic
Wellbutrin SR)?
For brand Wellbutrin XL requests, also answer the following*:
 Yes  No Does the member have a history of failure, contraindication, or intolerance to bupropion extended-release (generic
Wellbutrin XL)?
*May not apply to all plans
Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to
this review?
________________________________________________________________________________________________________________
Please note:
This request may be denied unless all required information is received.
For urgent or expedited requests please call 1-800-711-4555.
This form may be used for non-urgent requests and faxed to 1-800-527-0531.
______________________________________________________________________________________________________________
This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider
named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose
PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information
in this document is against the law. If you are not the intended recipient, please notify the sender immediately.
Office use only: Wellbutrin_UHCE&I_2016Feb-W.doc