Get Trulicity Prior Authorization Request Form Member ... - Optumrx

Filling out the Trulicity Prior Authorization Request Form accurately is essential for ensuring timely processing of medication requests. This guide will provide you with step-by-step instructions to help you navigate the form efficiently.

Follow the steps to complete your prior authorization request effectively.

1. Press the ‘Get Form’ button to access the Trulicity Prior Authorization Request Form. Open it in your preferred online editing tool.
2. Begin by filling out the member information section. This includes the member's name, insurance ID number, date of birth, street address, city, state, and zip code. Ensure all details are accurate.
3. Next, complete the provider information section. Fill in the provider's name, NPI number, office phone, office fax, specialty, and the office's street address. Again, double-check for accuracy.
4. In the medication information section, specify the medication name and strength required. Indicate if you are requesting the brand version, and if this request is for a continuation of therapy. Also, indicate whether the physician is supplying the medication.
5. Provide the directions for use and select the dosage form of the medication as needed.
6. In the clinical information section, select 'type 2 diabetes mellitus' if applicable, or specify another diagnosis along with the relevant ICD-10 codes. Ensure all relevant information is included.
7. Indicate any previous medications the patient has failed to tolerate or has had contraindications with by marking the corresponding options provided.
8. If a quantity limit is requested, specify the number of units needed per month and provide justification for exceeding the plan limitations.
9. Add any additional comments, diagnoses, symptoms, medications tried, or other information that may be pertinent for the review.
10. After completing all sections, review the entire form for any errors or omissions. Save your changes, and then download, print, or share the form as needed.

Complete your Trulicity Prior Authorization Request Form online to facilitate prompt processing.