Get Epclusa Prior Authorization Request Form (page 1 Of 2 ... - Optumrx

Filling out the Epclusa Prior Authorization Request Form is an important step in obtaining medication coverage. This guide will help users navigate through each section of the form efficiently and effectively.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access and open the Epclusa Prior Authorization Request Form in your preferred editor.
2. Begin by entering the required member information, including the member’s name, insurance ID number, date of birth, and street address.
3. Next, fill in the provider information with the provider's name, NPI number, office phone, fax, and address details.
4. In the medication information section, enter the medication name and strength. Be sure to check the box if you are requesting the brand or if this request is for continuation of therapy.
5. Specify the directions for use and select the appropriate dosage form.
6. In the clinical information section, indicate the diagnosis by selecting ‘Chronic Hepatitis C’ or noting any other diagnosis. Provide the relevant ICD-10 code.
7. Answer the yes or no questions regarding the submission of medical records and the patient's hepatitis C virus genotype.
8. Indicate if Epclusa is prescribed by a qualified specialist and whether it will be used in combination with other medications.
9. Respond to all additional questions regarding the patient's history of treatment and current status.
10. In the quantity limit requests section, specify the quantity requested per day and provide a reason for exceeding plan limitations.
11. Finally, review all sections for completeness and accuracy. Save any changes you may have made, and ensure you download or print the form to share as necessary.

Complete your Epclusa Prior Authorization Request Form online today for efficient processing.