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OptumRx. com and click Health Care Professionals OptumRx M/S CA 106-0286 3515 Harbor Blvd. Costa Mesa CA 92626 Prior Authorization Request Form Member Information required Provider Information required Member Name Provider Name Insurance ID NPI Date of Birth Office Phone Street Address Office Fax City State Phone Zip Specialty Office Street Address Medication Information required Medication Name Strength Is This Medication a New Start Yes No Dosage Form Directions for Use Clinical Information required Select the diagnosis below Adjunct to surgery and radioiodine therapy in the management of thyrotropin-dependent well-differentiated thyroid cancer Hypothyroidism Other diagnosis ICD-9/10 Code s Select the medications the member has a failure contraindication or intolerance to Are there any other comments diagnoses symptoms medications tried or failed and/or any other information the physician feels is important to this review Please note This request may be denied unless all required information is received. If the patient is not able to meet the above standard prior authorization requirements please call 1-800-711-4555. Please note All information below is required to process this request For urgent requests please call 1-800-711-4555 Mon-Fri 5am to10pm Pacific / Sat 6am to 3pm Pacific For real time submission 24/7 visit www. For urgent or expedited requests please call 1-800-711-4555. This form may be used for non-urgent requests and faxed to 1-800-527-0531. This document and others if attached contain information from OptumRx that is privileged confidential and/or may contain protected health information PHI. We are required to safeguard PHI by applicable law. The information in this document is for the sole use of the person s or company named above. Proper consent to disclose PHI between these parties has been obtained* If you received this document by mistake please know that sharing copying distributing or using information in this document is against the law. If you are not the intended recipient please notify the sender immediately and return the document s by mail to OptumRx Privacy Office 17900 Von Karman M/S CA016-0101 Irvine CA 92614. For urgent or expedited requests please call 1-800-711-4555. This form may be used for non-urgent requests and faxed to 1-800-527-0531. This document and others if attached contain information from OptumRx that is privileged confidential and/or may contain protected health information PHI. This document and others if attached contain information from OptumRx that is privileged confidential and/or may contain protected health information PHI. We are required to safeguard PHI by applicable law. The information in this document is for the sole use of the person s or company named above. We are required to safeguard PHI by applicable law. The information in this document is for the sole use of the person s or company named above. Proper consent to disclose PHI between these parties has been obtained* If you received this document by mistake please know that sharing copying distributing or using information in this document is against the law..

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