Get Proton Pump Inhibitors Prior Authorization Request Form ... - Optumrx

This guide provides comprehensive instructions on how to accurately complete the Proton Pump Inhibitors Prior Authorization Request Form for OptumRx. Following these steps will ensure that all necessary information is provided, facilitating a smooth authorization process.

Follow the steps to successfully complete your request form.

1. Press the ‘Get Form’ button to access the Proton Pump Inhibitors Prior Authorization Request Form and open it for editing.
2. Begin by filling out the Member Information section. Be sure to include the member’s name, insurance ID number, date of birth, and address details.
3. Next, complete the Provider Information section. Insert the provider's name, NPI number, office phone, fax, and street address.
4. In the Medication Information section, specify the medication name, strength, and whether this is a new start. Provide directions for use and dosage form.
5. Proceed to the Clinical Information section. Select the appropriate diagnosis from the options provided, and add any necessary ICD-9/10 codes.
6. Indicate any medications that the member has a failure, contraindication, or intolerance to. Confirm whether the patient has used the selected medication(s) recently.
7. Answer questions regarding the continuation of therapy and ability to swallow medication, as well as any additional clinical use considerations.
8. If applicable, fill in the reauthorization request section detailing the history of failure to step-down therapy and related queries.
9. Complete the quantity limit requests section by indicating the quantity requested per month and answering any related questions.
10. Finally, review all entered information for accuracy. Save your changes, and then proceed to download, print, or share the completed form as necessary.

Complete your Proton Pump Inhibitors Prior Authorization Request Form online today.