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

This guide provides a comprehensive overview of how to efficiently complete the Clemastine Prior Authorization Request Form online. By following the outlined steps, users can ensure that all necessary information is accurately submitted to facilitate a smooth authorization process.

Follow the steps to successfully complete the authorization request form.

1. Press the ‘Get Form’ button to access the Clemastine Prior Authorization Request Form and open it in your editor of choice.
2. Begin by entering the member's information in the designated fields. This includes the member's name, date of birth, and insurance ID number. Make sure to complete all required fields marked accordingly.
3. Next, fill in the Provider Information section. You will need to provide the provider's name, National Provider Identifier (NPI) number, office phone, street address, city, state, and zip code.
4. Proceed to the Medication Information section. Input the medication name, strength, directions for use, and dosage form. Also indicate whether this medication is a new start by selecting 'Yes' or 'No'.
5. In the Clinical Information section, select the appropriate diagnosis from the provided options. If applicable, specify any other diagnosis along with the corresponding ICD-9/10 code.
6. Acknowledge the risk information by selecting 'Yes' or 'No' for both questions regarding aging population and the necessity of the drug. Enter any other medications that the member has failed, has contraindications for, or has shown intolerance to.
7. Provide any additional comments, diagnoses, symptoms, or medications that may be relevant for the review. It is important to include as much detail as necessary for a comprehensive evaluation.
8. Once all sections are completed, review the form for accuracy and completeness before proceeding to save your changes, download, print, or share the form as needed.

Start filling out the Clemastine Prior Authorization Request Form online today to ensure a timely authorization process.