Bylvay enrollment forms

Complete and submit the forms to Optum Frontier Therapies.


Sending your prescription

To submit a Bylvay prescription, the prescribing provider will need to complete a therapy enrollment form and also supply a patient consent form below. 

  • When filling out the therapy enrollment form, be sure to note Optum Frontier Therapies as your preferred pharmacy.
  • Once the prescribing provider and the patient complete and sign these two forms, the prescription is ready to submit.

Find more information on the three ways to send us a prescription here.