Get Xel Patch Prior Authorization Request Form ... - Optumrx

Filling out the Xel Patch Prior Authorization Request Form is a crucial step in ensuring that patients receive the medications they need. This guide provides clear, step-by-step instructions to help healthcare professionals complete the form accurately and efficiently.

Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to access the Xel Patch Prior Authorization Request Form and open it for editing.
2. Begin filling out the 'Member Information' section by providing the member's name, insurance ID number, date of birth, and other required details.
3. Next, complete the 'Provider Information' section including the provider's name, NPI number, office phone, street address, city, state, and zip code.
4. In the 'Medication Information' section, input the medication name, strength, whether this is a new start, directions for use, and dosage form.
5. Proceed to the 'Clinical Information' section. Select the appropriate diagnosis, and indicate any medications the member has failed or experienced intolerances to.
6. Fill in the requested quantity per day and provide a reason for exceeding the plan limitations, selecting one or more of the given options.
7. Offer any additional comments or pertinent information that may assist in the prior authorization review.
8. After completing the form, ensure all required fields are filled in correctly. Save your changes, then download, print, or share the form as necessary.

Complete your documents online for smooth processing.