Get Flector & Prior Authorization Request Form ... - Optumrx

Filling out the Flector & Prior Authorization Request Form is an important step in ensuring that patients receive the necessary medications. This guide is designed to provide clear, step-by-step instructions for users to complete the form accurately and efficiently online.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the member information in the designated section. This includes the member's name, insurance ID number, date of birth, and address.
3. Next, provide the provider information, which should include the provider's name, NPI number, office phone, and address.
4. In the medication information section, input the name of the medication, its strength, and indicate if this medication is for a new start. Additionally, fill in the directions for use and dosage form.
5. Proceed to the clinical information section. Select the appropriate diagnosis and provide ICD-9/10 codes where necessary. List any medications the patient has previously failed, had contraindications to, or were intolerant of.
6. For quantity limit requests, specify the quantity requested per day and provide a reason if exceeding plan limitations.
7. Finally, leave any additional comments or important information that could assist in the review process. Ensure all required fields are completed to avoid any delays.
8. Once the form is fully filled out, you can save changes, download, print, or share the form as needed.

Complete your forms online today for a smooth submission process.