Follow the steps to complete the prior authorization request form.

1. Click ‘Get Form’ button to access the prior authorization request form and open it in your chosen editor.
2. Begin by filling out the 'Member Information' section. Provide the member's name, insurance ID number, date of birth, and contact information, including phone and address.
3. Next, complete the 'Provider Information' section. Input the provider's name, NPI number, office phone, specialty, and office address details.
4. Move to the 'Medication Information' section. Specify the medication name, strength, check the option if requesting the brand, and indicate if this is a continuation of therapy, along with directions for use and dosage form.
5. Proceed to the 'Clinical Information' section. Select the appropriate diagnosis from the options, provide ICD-10 codes, and answer the clinical questions. Ensure to specify if the medication is for localized pain or if there are any treatment failures with other NSAIDs.
6. Fill in the 'Quantity Limit Requests' section. State the quantity requested per day and provide a reason for exceeding any plan limitations, selecting the most relevant option.
7. In the last section, include any additional comments or pertinent information that may assist in the authorization review.
8. After completing all sections, review the form for accuracy, then save your changes. You may also choose to download, print, or share the completed form as needed.

Complete your OptumRx Flector (Diclofenac Epolamine) Prior Authorization Request Form online today.