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

This guide provides clear instructions on how to effectively complete the ® & -Dot® Prior Authorization Request Form online. By following these steps, users can ensure that all necessary information is submitted accurately for timely processing of the request.

Follow the steps to fill out the form successfully.

1. Press the ‘Get Form’ button to access the request form and open it in your preferred editor.
2. Begin by filling in the required Member Information section, which includes the member's name, insurance ID number, and date of birth. Ensure that the details accurately reflect the member’s current information.
3. Proceed to the Provider Information section. Enter the provider's name, NPI number, office phone, fax number, and address details. Accuracy in this section will help facilitate communication.
4. In the Medication Information section, input the relevant medication name and strength. Indicate whether this medication is a new start by selecting 'Yes' or 'No'.
5. Provide directions for use and specify the dosage form of the medication clearly to avoid any ambiguity.
6. Move to the Clinical Information section and select the appropriate diagnosis from the list provided, including options for hypoestrogenism, postmenopausal osteoporosis, and vasomotor symptoms.
7. Acknowledge the risk assessment by checking the corresponding boxes regarding the provider's acknowledgment of risks in the age 65 and older population and attestation of medication efficacy.
8. For each diagnosis selected, indicate any medications that the member has a failure, contraindication, or intolerance to by checking the relevant boxes.
9. Fill in the Quantity Limit Requests section by specifying the quantity of medication requested per month and providing a reason for exceeding standard plan limitations.
10. Add any additional comments or pertinent information that may assist in the review process in the space provided.
11. Finally, review all sections for completeness and accuracy before submitting the form. Once finalized, you can save changes, download the form, print it, or share it as required.

Start filling out your request form online today for efficient processing.