Get Prior Authorization Request Form Member ... - Optumrx

Filling out the Prior Authorization Request Form is an essential step in obtaining medication approval for patients covered by OptumRx. This guide provides a clear and supportive approach to help users complete the form accurately and efficiently.

Follow the steps to effectively complete the form.

1. Use the ‘Get Form’ button to access the Prior Authorization Request Form and open it for editing.
2. Begin with the Member Information section. Fill in the member's name, insurance ID number, date of birth, and contact information including street address, phone number, and zip code.
3. Next, move to the Provider Information section. Ensure you enter the provider name, NPI number, office phone and fax numbers, and the provider's specialty, along with their office address details.
4. Proceed to the Medication Information section. Input the medication name, strength, and whether this is a new medication start. Include directions for use and the dosage form as well.
5. In the Clinical Information section, select the appropriate diagnosis from the options provided, or specify another diagnosis along with the corresponding ICD-9/10 code. Record any medications the patient has previously failed, had a contraindication to, or experienced intolerance to.
6. For quantity limit requests, specify the amount of medication needed per day and indicate the reason for exceeding the plan limitations. Choose the applicable reason from the options provided or add a custom explanation.
7. Lastly, include any other comments, relevant diagnoses, symptoms, or additional information that the physician believes is significant to the request.
8. After completing all sections of the form, review your entries for accuracy. You can then save changes to the form, download it, print, or share it as needed.

Complete the Prior Authorization Request Form online for a smooth submission process.