17 0 obj endobj Create an account using your email or sign in via Google or Facebook. uuid:94c837f8-2907-48ac-b6be-ad7166d0dcfe Click here to view the OptumRx PA guidelines and Exception Request Procedures. endobj <>/Font<>>>/Fields[293 0 R 301 0 R 294 0 R 302 0 R 303 0 R 295 0 R 304 0 R 296 0 R 305 0 R 297 0 R 298 0 R 299 0 R 306 0 R 300 0 R 307 0 R 308 0 R 309 0 R 310 0 R 311 0 R 312 0 R 317 0 R 318 0 R 319 0 R 320 0 R 321 0 R 322 0 R 323 0 R 324 0 R 325 0 R 330 0 R 331 0 R 334 0 R 335 0 R 336 0 R 8 0 R 314 0 R 315 0 R 326 0 R 327 0 R 329 0 R 328 0 R 332 0 R 333 0 R 313 0 R 373 0 R]>> If you cannot submit requests to the OptumRx PA department through ePA or telephone,click here. that will help the reviewing process. Over 2/3 of the PAs that we receive each year are now electronic. If the physician is supply the medication, check that this is the case. `HJsCiG:!HY5VX1rAZvdZ After financial statements 497330829 form, Electronic signature Illinois High Tech Lease Agreement Form Free, Electronic signature Wyoming Education Lease Template Secure, Electronic signature Illinois High Tech Lease Agreement Form Secure, Electronic signature Illinois High Tech Lease Agreement Form Fast, Electronic signature Wyoming Education Lease Template Fast, Electronic signature Illinois High Tech Lease Agreement Form Simple, Electronic signature High Tech Word Indiana Online, Electronic signature Illinois High Tech Lease Agreement Form Easy, Electronic signature Illinois High Tech Lease Agreement Form Safe, Electronic signature Wyoming Education Lease Template Simple, Electronic signature High Tech Word Indiana Computer, Electronic signature Wyoming Education Lease Template Easy, How To Electronic signature Illinois High Tech Lease Agreement Form, Electronic signature Wyoming Education Lease Template Safe, How Do I Electronic signature Illinois High Tech Lease Agreement Form, Help Me With Electronic signature Illinois High Tech Lease Agreement Form, Electronic signature High Tech Word Indiana Mobile, How Can I Electronic signature Illinois High Tech Lease Agreement Form, Can I Electronic signature Illinois High Tech Lease Agreement Form, Electronic signature Illinois High Tech Permission Slip Online. Proper consent to disclose PHI between these parties has been obtained. 12 0 obj Find OptumRx formularies, formulary updates . The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 398 0 obj hb```g``fa`e`X}A@,3.Y600Ix^
` OptumRx is not authorized to review requests for medications supplied by the physicians office. OptumRX Prior Prescription Authorization Form. 1 - CoverMyMeds Provider Survey, 2019. 342 0 obj
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O4 Footer. endobj 158 0 obj Follow the instructions below to fill out Optumrx tier exception form online quickly and easily: 13 0 obj You can submit a verbal PA request. <>/Metadata 3 0 R/Pages 136 0 R/StructTreeRoot 7 0 R/Type/Catalog/ViewerPreferences 159 0 R>> Show details How it works Open the covermymeds prior authorization form pdf and follow the instructions Easily sign the covermymeds optumrx with your finger Open PDF, opens in a new tab or window. Go to the Chrome Web Store and add the signNow extension to your browser. h}]ui#gVmv. ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Our electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible. Prior authorization (PA) requires your doctor to tell us why you are taking a medication to determine . To ensure that a PA determination is provided to you in a timely This form may be sent to us by mail or fax: Address: OptumRx . endobj
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This form may be used for non-urgent requests and faxed to 1-800-527-0531. hbbd```b``[A$;fGH."Y@${8
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Provider named above is required to safeguard PHI by applicable law. You need to record the rights and responsibilities of the sides within the field. Step 6 Check the yes box to indicate that all the information provided is both true and accurate. prescription drug benefits may be covered under his/her plan-specific formulary for which See buprenorphine/naloxone tab prior authorization criteria Additionally, a documented allergy to inactive ingredient in preferred product that is not in requested product 12/3mg: 1/day 8/2mg: 2/day 4/1mg: 2/day 2/0.5mg: 3/day ^ Zubsolv NP . Prior Authorization Request Form Please complete this entire form and fax it to: 866-940-7328. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. 1 0 obj
If you are new to electronic prior authorizations (ePA), here are a few benefits to consider: Saves time: Providers who report using ePA submissions on average spend 2.5 fewer hours on PAs per week*, Provides real-time submissions with typical resolutions in less than 5 minutes at no additional cost, Eliminates wait time on the phone or using manual fax forms, Reduces disruptions to patient care, Allows renewals to be created from previous submissions, Includes specific clinical questions pertinent to patient plan requirements, Reduces paperwork: Process is eco-friendly, Protects patient health information: Provides secure transmission using the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard, Save time today and submit your PA requests to OptumRx through any of the following online portals:**. y?S} T If yes, answer the two accompanying questions. QA7"/>-[x/*nt{]1a=RpLp|7{-6NxfO_Zk~[Z`M'h]|^whH}v;vlnk~ ]W{AlB:2Gt!mxzG
qa>OW=PIvCqX ^ 4e*Y wo.Hp^?.Mo\||>^3u{-dth"dhxBg?;JLu &i/ncQ7ADjZ wFrv. submitting pharmacy prior authorization requests for all plans managed by %PDF-1.7
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Please complete all pages to avoid a delay in our decision. manner, please submit all information needed to make a decision. 15 0 obj Find the extension in the Web Store and push, Click on the link to the document you want to design and select. All Rights Reserved. Optum Prior Authorization Criteria Specific Forms. It has significantly reduced the paperwork burden of my office and office staff as far as prior authorizations go. 193 0 obj See buprenorphine/naloxone tab prior authorization criteria You may also ask us for a coverage determination by calling the member services number on the back of your ID card. <>stream
Press Done after you fill out the blank. endobj . Authorization form - English PDF Formulario Estndar de Autorizacin para la Divulgacin de Informacin de Salud Protegida (PHI) (Espaol) Usamos este formulario para obtener su consentimiento por escrito para divulgar su informacin de salud protegida (protected health information, PHI) a alguien que usted haya designado. 414 0 obj
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That's why we have a team of experts and a variety of help resources to make requests faster and easier. OptumRx's Preferred Method for Prior Authorization Requests Our electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible. As an OptumRx provider, you know that certain medications require approval, or ee` fd Please contact the OptumRx Prior Authorization department at 1-800-711-4555 or . ' @}\,@:uX AS ~ -
If requesting a brand, select the appropriate box. Once a review is complete, the provider is informed whether the PA request has been approved or Submitting a PA request Did you know Over 2/3 of the PAs that we receive each year are now electronic. To exercise your rights under HIPAA, click here. <> 8X R@,
f`\iW sXXNe`pj! the OptumRx UM Program. therapy and non-formulary exception requests. We use this form to obtain your written consent to disclose your protected health information to someone designated by you. 2016-09-16T07:22:50.000-05:00 140 0 obj If you cannot submit requests to the OptumRx PA department through ePA or telephone,click here. Verify your NPI to receive all requests initiated at your patients pharmacies, Use your account to initiate, access and submit requests, HIPAA compliant and available for all plans and all medications. Lack of information may delay Make adjustments to the template.
Open PDF, . Super Fast Download Medicaid Prior Authorization video HD Youtube HD. ePA is a secure and easy method for submitting,managing, tracking PAs, step For urgent or expedited requests please call 1-800-711-4555. Supply the diagnosis followed by a list of medications that have been tried and failed and the date on which each drug was prescribed. En el caso de los Representantes Personales que hayan sido legalmente designados, pueden llenar este formulario y adjuntar documentacin legal de respaldo, tales como un Poder que indique la autoridad total para tomar decisiones sobre la atencin de la salud, documentacin de la tutela, etc. LET's GET STARTED. P.O. This form must be completed in full and double checked for accuracy before being faxed to the insurance company for review. DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. Box 25183 . This form may be used for non-urgent requests and faxed to 1-800-527-0531. Optum Prior Authorization Criteria Specific Forms. Open PDF, opens in a new tab or window. Your patients DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . Please review each document for more details. denied. Start a Request Scroll To Learn More Why CoverMyMeds <>stream
Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. OptumRX Prior Prescription Authorization Form Step 2 - The first required information is that of the member. 192 0 obj <> 2 - Express Scripts data on file, 2019. Call 1-800-711-4555, 5 a.m. 10 p.m. PT, Monday-Friday and 6 a.m. 3 p.m. PT, Saturday. 0
138 0 obj endobj Select the area where you want to insert your signature and then draw it in the popup window. Utilization management updates . Formulario de autorizacin - PDF en espaol. Prior Authorization Request Form Author: Miley, David T Subject: OptumRx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations. Click the New Document option above, then drag and . Before doing so however, enter in any other comments, diagnoses, symptoms etc. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against . 1 OptumRx Prior Authorization Health care professionals website Prior authorization for prescribers Prior authorizations (PAs) help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. It enables a faster turnaround time of stream
endobj Optum Prior Authorization Criteria Specific Forms Injectable Psychotropic - Optum Open PDF Neuromuscular - Optum - Achalasia, Chronic Anal Fissure, Detrusor Overactivity, Spasticity, Bleopharospasm Open PDF Neuromuscular - Optum - Migraine, Cervical Dystonia, Overactive Bladder Open PDF RSV- Optum Open PDF **The ePA solution supports all forms of PA and formulary exception requests. The following January 1, 2023 flyers are sent to members to outline the drugs affected by prior authorization, quantity limits, and step therapy based on benefit plan designs. Use this form to consent to the release of verbal or written PHI, including your profile or prescription records, to your designated person, named in the form. Submitting a PA request to OptumRx via phone or fax. Prior Prescription (RX) Authorization Forms, OptumRX Prior Prescription (Rx) Authorization Form, CVS Prior Prescription (Rx) Authorization Form, CIGNA Prior Prescription (Rx) Authorization Form, Future Scripts Prior Prescription (Rx) Authorization Form, Meridian Prior Prescription (Rx) Authorization Form, Amerigroup Prior Prescription (Rx) Authorization Form, EnvisionRX Prior Prescription (Rx) Authorization Form, Humana Prior Prescription (Rx) Authorization Form, Harvard Pilgrim Healthcare Prior Prescription (Rx) Authorization Form, Authorization Forms Adobe PDF and Microsoft Word. Submitting prior authorizations via ePA (electronic prior authorization) is the fastest and most convenient method for submitting prior authorizations. This will require the following: Step 4 The medications name, strength and dosage form must be enter next. <>stream
If you are new to electronic prior authorizations (ePA), here are a few benefits to consider: Saves time: Providers who report using ePA submissions on average spend 2.5 fewer hours on PAs per week*, Provides real-time submissions with typical resolutions in less than 5 minutes at no additional cost, Eliminates wait time on the phone or using manual fax forms, Reduces disruptions to patient care, Allows renewals to be created from previous submissions, Includes specific clinical questions pertinent to patient plan requirements, Reduces paperwork: Process is eco-friendly, Protects patient health information: Provides secure transmission using the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard, Save time today and submit your PA requests to OptumRx through any of the following online portals:**. Install the signNow application on your iOS device. endobj Click thislinkto leverage theAMA's video seriesto educate your staff about the advantages of ePA. 141 0 obj Member Information Prescriber Information Member Name: Provider Name . covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. 17 January, 2018 Introduction to OptumRx. 2016-12-02T11:43:26.719-06:00 <>/MediaBox[0 0 612 792]/Parent 136 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> Providers. (f` pe%TfVAXY.K3`(o]"_0q_fb`` 1 Exclusions may include cost reduction requests such as tiering exception, copay waiver, and tier cost sharing.To submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., HCR), please contact the OptumRx PA department through Click on New Document and select the form importing option: upload Optumrx prior authorization form pdf 2021 from your device, the cloud, or a protected link. 2023 CoverMyMeds LLC. encourage providers to submit PA requests using the ePA process as described Improving efficiencies without sacrificing the essentials, Three Easy steps to completing requests electronically. Submit a prior authorization; Utilization management changes, effective 01/01/23; DPL Main Nav Items . Specialty drugs typically require a prior authorization. 2016-09-16T07:22:50.000-05:00 Enter in the date and, once the document has been printed off, sign the signature field. endobj If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. hb``b``*`bd1! OptumRx Prior Authorization Form is a great way to get the drugs you need. Our site is the place to go if you want to edit and acquire this form. Electronic payment solutions; FAQs; Fraud, waste, abuse and general compliance; Forms; Formulary and updates; Guides, manuals and training; Notices; Payer sheets; See all; DPL Main Nav Items. OptumRx Prior Authorization and Exception Request Procedures Submitting an electronic prior authorization (ePA) request to OptumRx ePA is a secure and easy method for submitting,managing, tracking PAs, step therapy and non-formulary exception requests. Select the document you want to sign and click. I have been using this service since last year and it simply gets better and better. reason prescribed before they can be covered. Loginto your preferred web-based portal account and select New Requestwithin If you have questions, please call 800-310-6826. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization [19 0 R 21 0 R 22 0 R 24 0 R 186 0 R 187 0 R 187 0 R 187 0 R 187 0 R 187 0 R 184 0 R 185 0 R 185 0 R 185 0 R 185 0 R 185 0 R 183 0 R 180 0 R 179 0 R 178 0 R 175 0 R 174 0 R 173 0 R 172 0 R 168 0 R 167 0 R 166 0 R 163 0 R 162 0 R 161 0 R 158 0 R 157 0 R 156 0 R 155 0 R 154 0 R 149 0 R 148 0 R 147 0 R 146 0 R 145 0 R 139 0 R 140 0 R 140 0 R 140 0 R 140 0 R 140 0 R 138 0 R 135 0 R 136 0 R 134 0 R 133 0 R 132 0 R 128 0 R 127 0 R 126 0 R 123 0 R 122 0 R 119 0 R 118 0 R 114 0 R 115 0 R 115 0 R 115 0 R 115 0 R 115 0 R 113 0 R 100 0 R 101 0 R 102 0 R 103 0 R 104 0 R 105 0 R 106 0 R 107 0 R 108 0 R 109 0 R 110 0 R 111 0 R 99 0 R 56 0 R 57 0 R 58 0 R 97 0 R 96 0 R 93 0 R 92 0 R 89 0 R 88 0 R 85 0 R 84 0 R 81 0 R 78 0 R 79 0 R 80 0 R 75 0 R 74 0 R 71 0 R 70 0 R 60 0 R 55 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 20 0 R 25 0 R 188 0 R 191 0 R 189 0 R 27 0 R 28 0 R 23 0 R] Open the doc and select the page that needs to be signed. Use the Sign Tool to add and create your electronic signature to signNow the Prior Authorization Request Form Member . 195 0 obj Prior authorizations (PAs) help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. The American Medical Association (AMA) wants to help bring ePA awareness to physician practices. Fax Number: 1-844-403-1028 Prior Authorization Department . For urgent or expedited requests please call 1-800 -711 -4555. <>stream
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196 0 obj coverage determinations for most PA types and reasons. review decisions on sound clinical evidence and make a determination within the timeframe Step 3 Next, to the right of the member info, supply the healthcare provider info. 16 0 obj Utilize a check mark to point the choice wherever required. endobj
(Hours: 5am PST to 10pm PST, Monday through Friday. 1.1 Call 1-800-711-4555, 5 a.m. 10 p.m. PT, Monday-Friday and 6 a.m. 3 p.m. PT, Saturday. Microsoft Word 2010 2016-12-02T11:43:26.506-06:00 **The ePA solution supports all forms of PA and formulary exception requests. Now you may print, download, or share the form. Crohn's/Ulcerative Colitis. Other ways to submit a prior authorization, Having difficulties with ePA? For requests for buy and bill, please contact the patients medical benefit. %PDF-1.7
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Download Enrollment Forms. Use este formulario para dar su consentimiento para la divulgacin de la informacin de salud protegida tanto verbal como escrita, que incluye su perfil o registro de recetas, a la persona que usted haya designado en el formulario. For forms to request prior authorization for drugs covered under the retail pharmacy benefit, please visit the OptumRx Healthcare Professionals Portal. This form may be used for non-urgent requests and faxed to 1-844 -403 -1028 . We strongly Download now. Optimal. Create your signature, and apply it to the page. If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. OptumRx has partnered with CoverMyMeds to receive prior authorization requests, . %PDF-1.6
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Now you'll be able to print, download, or share the document. <> Santa Ana, CA 92799 . Use this form in Arizona, Nevada and Utah. 0 The American Medical Association (AMA) wants to help bring ePA awareness to physician practices. Optumrx Prior Authorization Appeal Form 2019-2023 Use a go covermymeds optumrx 2019 template to make your document workflow more streamlined. Add the PDF you want to work with using your camera or cloud storage by clicking on the. Add the Optumrx prior authorization form for redacting. Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE. 752dc44aac14d1f9c79b428b5625173e746a1557 2016-09-15T12:53:17.000-05:00 %
signNow makes signing easier and more convenient since it provides users with a range of additional features like Invite to Sign, Add Fields, Merge Documents, and many others. Step 3: Click the Done button to save the file. V3`#lK2m%\ekvNYN9(^,4b"wx?_y=X]>d''x7|{rO0slTZcL(A$9cOij&KM?|PW( ~?:
,5/V!}=#Y:w53~))$VS|4Bq")rUj7nN'7C|v C*rMFDMdb)y]E*DJc 05ZAk YyY_4NdEsAk^OI"@D_ 02 Refer to the Support section or contact our Support crew in the event that you have any concerns. Step 2 The first required information is that of the member. 216205 requests and determinations, OptumRx is retiring most fax numbers used for We know PA requests are complex. 1-855-427-4682. After that, your optimal prior authorization form is ready. OptumRx Prior Authorization Guidelines and Procedures July 1, 2022. Open PDF, opens in a new tab or window. Follow the Support section or get in touch with our Support team in the event that you have got any concerns. hbbd```b``:"@$"&&@${
"Y`. Search for the document you need to electronically sign on your device and upload it. Please note: All information below is required to process this request If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Dermatology. Arizona: Commercial Prescription Prior Authorization Form for Prescription Drug, DME-Medical Devices . HWn8}WiIJAdu$,d(j[~V&nge^U9UV ^<. OptumRx New Prescription Physician Fax Download - Medicaid Prior Authorization video, BNK.WIKI. It enables a faster turnaround time of coverage determinations for most PA types and reasons. In the two bottom windows, enter in the directions for use and whether or not it is a continuation of a current therapy. This info will allow those at OptumRX to determine whether or not partial or full coverage is feasible. <>/Metadata 398 0 R/Pages 192 0 R/StructTreeRoot 12 0 R/Type/Catalog>> %PDF-1.5
The advanced tools of the editor will lead you through the editable PDF template. Formulario de designacin de representante personal - PDF en espaol, Stay up to date on the latest OptumRx information, Medicaid customers, please use the appropriate state form below, The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to get it, change it, share it and monitor it. These rights are collectively known as Individual Rights. If denied, the provider may choose to prescribe a less costly but equally effective, alternative <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 15 0 R 16 0 R 17 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R 41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R 49 0 R 50 0 R 51 0 R 52 0 R 53 0 R 54 0 R 55 0 R 56 0 R 57 0 R 58 0 R 59 0 R 60 0 R 61 0 R 62 0 R 63 0 R 64 0 R 65 0 R 66 0 R 67 0 R 68 0 R 69 0 R 70 0 R 71 0 R 72 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. they may: No hold times. Injectable Psychotropic - Optum. Any device can be used, such as a phone, tablet, or laptop. endobj 139 0 obj That's why we have a team of experts and a variety of help resources to make requests faster and easier. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective For Personal Representatives that have been legally appointed, the Personal Representative can complete this form and attach supporting legal documentation, such as a Power of Attorney that indicates full health care decision-making authority, guardianship documentation, etc. Author: Miley, David T Created Date: 12/23/2022 9:56:07 AM . OptumRx, except for the following states: MA, RI, SC, and TX. For requests for buy and bill, please contact the patients medical benefit. We offer other various resources to help support your understanding and use of ePA. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED . Allow at least 24 hours for review. <> Sign in to the editor with your credentials or click Create free account to evaluate the tool's features. [292 0 R 293 0 R 294 0 R 295 0 R 296 0 R 297 0 R 298 0 R 299 0 R 300 0 R 301 0 R 302 0 R 303 0 R 304 0 R 305 0 R 306 0 R 307 0 R 308 0 R 309 0 R 310 0 R 311 0 R 312 0 R 314 0 R 315 0 R 316 0 R 313 0 R 373 0 R 317 0 R 318 0 R 319 0 R 320 0 R 321 0 R 322 0 R 323 0 R 324 0 R 325 0 R 326 0 R 327 0 R 328 0 R 329 0 R 330 0 R 331 0 R 332 0 R 333 0 R 334 0 R 335 0 R 336 0 R 337 0 R] endobj No phone trees. Send filled & signed optiumrx or save.