Get Optumrx Prior Authorization Form Printable

Completing the Optumrx Prior Authorization Form Printable is an essential step in obtaining approval for treatment. This guide will walk you through each section of the form, ensuring you include all necessary details for a successful submission.

Follow the steps to fill out the form accurately and efficiently.

1. Click the ‘Get Form’ button to access and open the Optumrx Prior Authorization Form Printable in your preferred viewing application.
2. Begin by filling out the Member Information section. Provide the member's full name, date of birth, and insurance ID number. Make sure to include all required contact details such as street address, city, state, zip code, and phone number.
3. Next, complete the Provider Information section. Enter the provider's name, office phone, office fax, street address, and their NPI number. It is important that this information is accurate and up-to-date.
4. Move to the Medication Information section. Here, specify the medication name and strength. Indicate whether this medication is a new start by selecting ‘Yes’ or ‘No’. Fill in the dosage form and directions for use.
5. In the Clinical Information section, choose the diagnosis that applies from the provided list, or fill in another diagnosis along with the corresponding ICD-9/10 codes if applicable. Note if the medication was prescribed by an eye specialist.
6. List any medications that the member has failed, has contraindications against, or has shown intolerance to as part of the information needed for approval.
7. If this is a reauthorization request, indicate whether the patient has shown a positive clinical response to therapy by selecting ‘Yes’ or ‘No’.
8. Provide any additional comments regarding the patient’s condition, symptoms, or specific medications tried, which may help in the review process.
9. Once you have completed all sections, carefully review the form to ensure all required fields are filled. After verification, you can save changes, download a copy, print it, or share it as necessary.

Start filling out your Optumrx Prior Authorization Form Printable online today to ensure timely processing of your request.