Get Capsule Prior Authorization Request Form ... - Optumrx

Completing the Capsule Prior Authorization Request Form is essential for ensuring that the necessary medications are authorized for your patients. This guide provides clear and detailed instructions on how to fill out the form accurately and effectively.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Capsule Prior Authorization Request Form. This will allow you to open the form in an editor for filling out.
2. Begin with the Member Information section. Enter the required details such as the member's name, date of birth, and insurance ID number. Provide accurate information to avoid delays.
3. Next, fill in the Provider Information section. Include the provider's name, office phone, and NPI number, along with the office street address, city, state, and zip code.
4. Proceed to the Medication Information section. Specify the medication name, strength, and whether this is a new start. Include directions for use and dosage form.
5. In the Clinical Information section, select the appropriate diagnosis. If applicable, provide an alternative diagnosis along with the corresponding ICD-9/10 code.
6. Indicate any medications the patient has previously failed or has contraindications to. Check the relevant boxes, and be mindful of the note about considering an alternative medication, tablets.
7. In the comments section, provide any additional information that may assist in the review process. This could include other diagnoses, medications tried, or important details from the provider.
8. Once all sections are completed, review the form for accuracy. After ensuring all information is correct, you can save changes, download, print, or share the form as needed.

Complete your prior authorization requests online to streamline the process.