Follow the steps to accurately complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your editing software.
2. Enter the member information, including the member's name, insurance ID number, and date of birth, ensuring all fields are filled out correctly.
3. Provide the provider information, including the provider's name, NPI number, office phone, and address.
4. Fill in the medication information, selecting the medication name, strength, and indication for use. Check the box if requesting a brand name or if this is a continuation of therapy.
5. Complete the clinical information section by selecting the appropriate diagnosis from the options provided and filling in the ICD-10 code.
6. Respond to the clinical information questions regarding the prescriber’s specialty, the patient’s history with topical corticosteroids, and their response to previous therapies.
7. If applicable, answer the questions related to reauthorization, documenting positive clinical responses to Dupixent therapy.
8. Fill out any additional comments or relevant information the physician considers important for the review.
9. Review the completed form to ensure accuracy, then save changes, download a copy, print, or share the form as needed.

Start filling out the Optumrx Dupixent Prior Authorization Form online to expedite your request.