Get Omnicare Medical Group Authorization Form

The Omnicare Medical Group Authorization Form is an essential document for requesting prior authorization for medications. This guide will assist you in completing the form online with clear instructions for each section.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Omnicare Medical Group Authorization Form and open it for editing.
2. Begin filling out the requesting physician details. Include the physician's name, office fax number, call center ID, office contact, phone number, and plan ID.
3. Provide the member information by entering the patient’s name, member ID, date of birth (DOB), and the date of the request.
4. In the medication information section, check whether the member has intractable migraine headache or cluster headache. If the answer is 'No,' please list the indication.
5. Answer questions regarding previous treatment trials. Indicate if the member has received an adequate trial of ® Nasal Spray, and, if applicable, describe the outcome or explain why not.
6. Indicate if the member has received an adequate trial of at least two 'triptan' medications. If so, list each drug and its trial outcome, or explain why not.
7. Confirm if the member has received an adequate treatment trial of ® injection, and provide details of the outcome or reasons for not receiving it.
8. Indicate any contraindications to D.H.E. 45® that may apply to the member by checking the relevant boxes.
9. Include any additional comments, if necessary. Review all filled sections for completeness and accuracy.
10. Have the requesting physician sign the form at the designated signature line.
11. Save your changes, then download, print, or share the completed form as required before submitting it to Coventry Health Care.

Complete your documents online today for a streamlined submission process.