Get Prior Authorization Request Form Member ... - Optumrx

Completing the Prior Authorization Request Form Member ... - OptumRx online is a straightforward process that ensures required medication approval is obtained efficiently. This guide provides detailed step-by-step instructions to help users accurately fill out the form for their needs.

Follow the steps to complete the Prior Authorization Request Form.

1. Press the ‘Get Form’ button to obtain and open the Prior Authorization Request Form Member ... - OptumRx in your preferred editing tool.
2. In the Member Information section, fill in the member's name, insurance ID number, and date of birth. Ensure that you provide accurate details to avoid processing delays.
3. Next, complete the Provider Information section with the provider's name, NPI number, office phone, and office street address including city, state, and zip code.
4. Proceed to the Medication Information section. Here, enter the medication name and strength, and indicate whether this medication is a new start. Specify the dosage form and provide clear directions for use.
5. In the Clinical Information section, select the appropriate diagnosis from the options provided. If applicable, include the ICD-9/10 code and specify if the medication was prescribed by a pain management or palliative care specialist.
6. Indicate any medications the member has failed, experienced contraindications, or demonstrated intolerances to within the specified options.
7. When addressing quantity limit requests, specify the quantity requested per month and the reason for exceeding plan limitations. Provide detailed justifications as necessary.
8. Finally, utilize the comments section to include any additional relevant information, diagnoses, symptoms, medications tried or failed, and other details critical for review.
9. Once all sections are completed, ensure all information is correct before saving your changes. You can then download or print the form for submission.

Start filling out your Prior Authorization Request Form online today to ensure timely processing.