Get 2016 Optumrx Prior Authorization Form

Completing the 2016 Optumrx Prior Authorization Form online is a straightforward process, designed to ensure that your prior authorization requests are submitted accurately. This guide provides step-by-step instructions to help you navigate the various sections of the form effortlessly.

Follow the steps to successfully fill out your form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling out the member information section. Provide the member's name, insurance ID number, date of birth, and contact information, including the street address, city, state, and zip code.
3. Next, fill in the provider information. Include the provider's name, NPI number, office phone, street address, and specialty. Ensure to accurately provide the office's location details.
4. Proceed to the medication information section. Enter the medication name, strength, dosage form, and directions for use. Specify whether this medication is a new start by selecting 'Yes' or 'No'.
5. In the clinical information section, select the appropriate diagnosis for the patient. Options include type 2 diabetes mellitus or an alternative diagnosis with required ICD-9/10 codes if applicable.
6. List any previous medications the patient has had a failure, contraindication, or intolerance to by selecting the options provided.
7. If requesting a quantity limit, indicate the requested quantity per day and explain the reason for exceeding plan limitations by selecting one of the provided options or specifying 'Other'.
8. Utilize the comments section to enter any additional information the physician deems necessary for the review, such as other diagnoses, symptoms, medications tried, or any relevant details.
9. After filling out all required sections, review your entries for accuracy and completeness. Once confirmed, save the changes made to the form.
10. You can download the completed form, print it for your records, or share it as needed.

Complete your Optumrx Prior Authorization Form online today for efficient processing.