Get Optumrx Movantik Prior Authorization Request Form 2015-2025

This guide provides clear instructions on how to complete the OPTUMRx Movantik Prior Authorization Request Form online. Following these steps will help ensure that your request is processed efficiently and accurately.

Follow the steps to complete the form correctly.

1. Click the ‘Get Form’ button to access the OPTUMRx Movantik Prior Authorization Request Form online.
2. Fill out the member information section, including the member's name, insurance ID, date of birth, and street address.
3. Complete the provider information section with the provider's name, NPI number, office phone, and address.
4. In the medication information section, provide the medication name, strength, dosage form, and check the box if requesting the brand. Include directions for use.
5. Indicate whether this is a continuation of therapy by selecting 'Yes' or 'No'. If 'Yes', answer the follow-up questions regarding past medication use and effectiveness.
6. Proceed to the clinical information section, select the applicable diagnosis for the request, and provide any additional comments or clinical information that may support the request.
7. Once all sections are completed, review the form for accuracy before finalizing.
8. You can save your changes, download, print, or share the form as needed.

Begin your process by completing the OPTUMRx Movantik Prior Authorization Request Form online today.