Get Prior Authorization Request Form Member ... - Optumrx

This guide provides users with a clear and comprehensive approach to completing the Prior Authorization Request Form for medications through OptumRx. By following these steps, users can ensure that all necessary information is accurately provided, facilitating an efficient review process.

Follow the steps to complete the prior authorization request form effectively.

1. Press the ‘Get Form’ button to retrieve the Prior Authorization Request Form and open it for editing.
2. Complete the member information section. This includes the member's name, insurance ID number, date of birth, street address, city, state, zip code, and other required details.
3. Fill in the provider information section. You will need to provide the provider's name, NPI number, office phone, office fax, and the office address.
4. In the medication information section, enter the medication name, strength, whether this is a new start (yes or no), dosage form, and directions for use.
5. Select the appropriate diagnosis from the options provided or specify another diagnosis along with the corresponding ICD-9/10 codes.
6. Indicate any medications the member has attempted and experienced failure, contraindication, or intolerance to by checking the applicable boxes.
7. Fill out the quantity limit requests, including the requested quantity per day and the reason for exceeding plan limitations, selecting from the options given.
8. Provide any additional comments or relevant clinical information that the physician considers important for this review.
9. Review all entered information to ensure accuracy and completeness. Remember, the request may be denied if required information is missing.
10. Once the form is completed, save your changes, and choose to download, print, or share the form as needed.

Begin your process now by filling out the Prior Authorization Request Form online.