Get Optumrx Dupixent Prior Authorization Request Form 2019-2025

Filling out the OptumRx Dupixent Prior Authorization Request Form online is a straightforward process that requires attention to detail. This guide will walk you through each section to ensure your submission is complete and accurate.

Follow the steps to successfully complete your authorization request.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by filling out the 'Member Information' section. Provide the member's name, date of birth, and insurance ID number. Ensure all information is accurate, as this information is crucial for processing the request.
3. Next, complete the 'Provider Information' section. Enter the provider's name, contact details, and NPI number. This information identifies the healthcare provider making the request.
4. In the 'Medication Information' section, specify the medication name, strength, and dosage form. Indicate if you are requesting the brand version and whether this is a continuation of therapy.
5. Proceed to the 'Clinical Information' section. Select the appropriate diagnosis from the provided options, such as asthma or atopic dermatitis, and enter the relevant ICD-10 codes.
6. For asthma inquiries, answer the specific questions regarding the patient's condition, current treatment, and past treatment history. This data assists in assessing the necessity of Dupixent therapy.
7. For atopic dermatitis, answer similarly to the asthma inquiries, focusing on the patient's treatment history and current disease status.
8. Complete any additional required fields and provide any comments or detailed reasons if specific conditions apply, particularly in the quantity limit section.
9. Review all information entered for accuracy and completeness. Once confirmed, you can save the form, download it, print it, or share it as necessary.

Start filing the OptumRx Dupixent Prior Authorization Request Form online today to ensure your healthcare needs are efficiently addressed.