Get Long Acting Opioids Prior Authorization Request Form ... - Optumrx

Filling out the Long Acting Opioids Prior Authorization Request Form requires attention to detail to ensure all necessary information is provided for processing your request. This guide will walk you through each section of the form and provide clear instructions on how to complete it effectively.

Follow the steps to fill out the Long Acting Opioids Prior Authorization Request Form

1. Press the ‘Get Form’ button to access the request form and open it in the editing tool.
2. Enter the member information in the designated fields, including the member’s name, date of birth, and insurance ID number.
3. Provide the provider information, including the provider’s name, NPI number, and contact details such as office phone and fax number.
4. Complete the medication information section by entering the medication name, strength, and the dosage form. Indicate whether it is a continuation of therapy.
5. Fill out the clinical information section by selecting the requested drug and diagnosis, then answer the necessary questions regarding the use of the medication.
6. In the medication history section, respond to questions related to the member’s history with specific opioid medications as required for the requested drug.
7. Fill out the quantity limit request by indicating the number of units requested per month and answering the related questions regarding the necessity for higher dosages.
8. Provide any additional comments, diagnoses, or important information that may aid in the review of the request.
9. Once all sections are completed, review the information carefully, save changes, and proceed to either download, print, or share the form as needed.

Take the next step and complete your Long Acting Opioids Prior Authorization Request Form online now.