Get Short-acting Beta Agonists Prior Authorization Request ... - Optumrx

Filling out the Short-Acting Beta Agonists Prior Authorization Request is a necessary step to ensure that your request is processed efficiently. This guide will provide you with clear, step-by-step instructions to help you complete the form accurately and effectively.

Follow the steps to successfully complete the authorization request form.

1. Press the ‘Get Form’ button to access the authorization request form and open it in the editor.
2. Fill out the member information including the member's name, date of birth, and insurance ID number. Ensure all details are accurate to facilitate processing.
3. Enter the provider information including the provider’s name, NPI number, office phone, and street address.
4. In the medication information section, specify the medication name and strength. Indicate if you are requesting the brand version or if this request is for a continuation of therapy.
5. Provide the directions for use and dosage form as required.
6. For clinical information, select the appropriate diagnosis from the options provided, or specify another diagnosis along with the ICD-10 code.
7. Indicate any medications that the patient has a failure, contraindication, or intolerance to by checking the relevant boxes.
8. If applicable, specify the quantity requested per month and provide the reason for exceeding any plan limitations.
9. Include any additional comments or critical information that may support the review of this request.
10. Review all sections for completeness and accuracy. Once satisfied, save your changes, download a copy of the form, and print or share it as necessary.

Begin filling out your prior authorization request online today.