Get Optumrx Emgality Prior Authorization Form

Filling out the Optumrx Emgality Prior Authorization Form online can be a straightforward process if you understand the required components. This guide provides clear and comprehensive instructions for each section of the form, making it easier for users to submit their requests accurately and efficiently.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred online editing tool.
2. Begin by entering the member information, including the member name, insurance ID number, date of birth, and their contact details.
3. In the provider information section, input the provider name, office phone, fax number, address, and specialty.
4. For medication information, include the medication name, strength, and specify if you are requesting the brand version. Provide directions for use and the dosage form.
5. In the clinical information section, select the diagnosis related to the request. If applicable, please fill in the ICD-10 codes.
6. Indicate whether the medication has been prescribed by or consulted with a neurologist or pain specialist.
7. Check any previous medications the patient has tried, documenting any failures, contraindications, or intolerances.
8. For chronic migraines, answer additional questions regarding diagnostic evaluations for medication overuse headache and treatment plans.
9. Fill out the section pertaining to quantity limits, stating the amount requested per month and the justification for any exceeding quantity.
10. Lastly, review all entries for accuracy and completeness before saving, downloading, printing, or sharing the form as needed.

Complete your documents online today for a streamlined experience.