Get Prior Authorization Request Form Member ... - Optumrx

Filling out the Prior Authorization Request Form is an essential step in ensuring that your medication is covered by your insurance plan. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the authorization request form.

1. Click ‘Get Form’ button to access the Prior Authorization Request Form. This will allow you to retrieve the necessary document to begin the submission process.
2. Fill out the member information section, which includes the member's name, insurance ID number, date of birth, and contact details. Make sure to provide accurate and complete information.
3. Complete the provider information section by entering the provider's name, NPI number, office phone, and fax number. This ensures that the authorization request is linked to the correct healthcare professional.
4. In the medication information section, specify the medication name, dosage strength, and whether this is a new start. It is also important to include directions for use and the dosage form.
5. Proceed to the clinical information section. Select the relevant diagnosis and provide the ICD-9/10 code if applicable. Indicate if the patient has a history of failure or intolerance to the medication.
6. Specify the quantity of medication requested per day and provide a reason for exceeding any plan limitations. Select relevant reasons from the options provided.
7. Utilize the comments section to input any additional information that may support the authorization request, such as other diagnoses or medications that have been tried.
8. Once all sections are completed, review the form for accuracy. You can then save your changes, download, print, or share the Prior Authorization Request Form as needed.

Complete your Prior Authorization Request Form online to ensure timely processing of your medication coverage.