Get () Prior Authorization Request Form ... - Optumrx

Filling out the ® () Prior Authorization Request Form online can streamline the process of obtaining necessary medication approvals. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form successfully

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Enter the required member information including the member's name, date of birth, and insurance ID#.
3. Fill in the provider information with the provider's name, NPI#, office phone, street address, city, state, and zip code.
4. In the medication information section, provide the medication name, strength, and indicate if this medication is a new start by checking 'Yes' or 'No'.
5. Complete the directions for use and specify the dosage form.
6. For clinical information, select the appropriate diagnosis from the options provided or specify an 'Other diagnosis' along with the corresponding ICD-9/10 code(s).
7. Indicate any medications the member has failed, had contraindications, or experienced intolerance to by checking the relevant boxes.
8. Specify the quantity requested per day and state the reason for exceeding the plan limitations, selecting from the provided options.
9. Provide any additional comments, diagnoses, symptoms, or information that may be pertinent to this review.
10. Once all sections are completed, save your changes, and proceed to download, print, or share the form as needed.

Take action today and submit your documents online to streamline your prior authorization requests!