Get Tier Cost Sharing Request Form - Optumrx

Filling out the Tier Cost Sharing Request Form - OptumRx is a critical step for healthcare providers seeking medication coverage for their patients. This guide provides clear instructions on how to effectively complete the form online in order to facilitate the approval process.

Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. In the Member Information section, fill in the required fields: Member Name, Insurance ID#, Date of Birth, and address details. Make sure to provide correct information as all are needed for processing.
3. Next, fill out the Provider Information section. Enter the Provider Name, NPI#, Office Phone, and the address of the office.
4. Move to the Medication Information section. Complete the following fields: Medication Name, Strength, and check the appropriate boxes if requesting brand or continuation of therapy. Provide Directions for Use and Dosage Form.
5. In the Clinical Information section, detail the patient’s diagnosis and include the relevant ICD-9/10 Code(s). List any medications the patient has tried and failed. Make sure to specify any supporting labs or test results.
6. Further provide a comprehensive list of all medications that the patient has tried for their condition. Include additional comments, diagnoses, and any other information deemed essential for the review.
7. Review all entries to ensure accuracy. Once completed, you may save changes, download, print, or share the form as needed.

Complete your Tier Cost Sharing Request Form - OptumRx online today to ensure timely processing.