Optumrx Prior Authorization Form PDF Details

Navigating the landscape of prescription medication approvals can often seem like a daunting process for both healthcare providers and patients. At the heart of this process is the OptumRx Prior Authorization form, a crucial document that serves as a gateway for obtaining necessary medications. This form, designed to be submitted by healthcare professionals, outlines the specific medical justification for the prescribed medication, ensuring that the patient's insurance plan covers it. OptumRx has streamlined this process by partnering with CoverMyMeds, providing a platform that not only facilitates these requests but also aims to deliver real-time determinations, significantly saving time for all parties involved. The form is meticulously detailed, requiring comprehensive information, including member and provider details, medication specifics, clinical justifications, and any other pertinent data that substantiates the need for the prescription in question. It’s important to note that these forms are regularly updated and may include barcodes for processing efficiency. Moreover, the document emphasizes its use for formal submissions only, advising against unauthorized replication for future use. This detailed approach underscores the importance of accurate and complete information, as any omission could impact the authorization outcome. Special considerations are also included for unique circumstances, such as requests exceeding typical dosage limits and considerations for the use of high-risk medications in elderly patients. This thorough documentation process is paramount in ensuring patients receive the medications they need, guided by a framework that prioritizes both efficacy and safety.

QuestionAnswer
Form NameOptumrx Prior Authorization Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesoptumrx medication prior authorization form pdf, optum rx pa form, optumrx prior authorization form pdf, optumrx prior authorization form

Form Preview Example

OptumRx has partnered with CoverMyMeds to receive prior authorization requests, saving you time and often delivering real-time determinations.

Visit go.covermymeds.com/OptumRx to begin using this free service.

Please note: All information below is required to process this request.

Mon-Fri: 5am to 10pm Pacific / Sat: 6am to 3pm Pacific

Prior Authorization Request Form (Page 1 of 2)

DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

 

Member Information (required)

 

 

Provider Information (required)

 

 

 

 

 

 

Member Name:

 

 

 

 

 

Provider Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance ID#:

 

 

 

 

 

NPI#:

 

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

Office Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

Office Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

State:

 

Zip:

 

Office Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

City:

 

State:

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication Information (required)

 

 

 

 

 

Medication Name:

 

 

 

 

 

Strength:

 

Dosage Form:

 

 

 

 

 

 

 

 

 

 

 

 

Check if requesting brand

 

 

 

 

Directions for Use:

 

 

 

 

 

Check if request is for continuation of therapy

 

 

 

 

 

 

 

 

 

 

 

Clinical Information (required)

 

 

 

 

 

Proactive Benefit Review:

 

 

 

 

 

 

 

 

 

 

 

Check if this is a proactive request for a 2020 benefit determination

 

 

 

 

 

What is the patient’s diagnosis for the medication being requested?

 

 

 

 

ICD-10 Code(s): _____________________________________

What medication(s) has the patient tried and had an inadequate response to? (Please specify ALL medication(s)/strengths tried, length of trial, and reason for discontinuation of each medication)

What medication(s) does the patient have a contraindication or intolerance to? (Please specify ALL medication(s) with the associated contraindication to or specific issues resulting in intolerance to each medication)

Are there any supporting labs or test results? (Please specify)

Use of High Risk Medications (HRMs) in the elderly (applies on patients ≥ 65 years ONLY):

"Use of High Risk Medications in the Elderly" is measure 238 of the Centers for Medicare & Medicaid Services Physician Quality Reporting System.

Does the provider acknowledge that this drug has been identified by the Centers for Medicare and Medicaid Services as a high risk medication in the 65 and older population? Yes No

Does the provider wish to proceed with the originally prescribed medication? Yes No

______________________________________________________________________________________________________________

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately.

Office use only: General_CMS_2019Oct-W

Prior Authorization Request Form (Page 2 of 2)

DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

Quantity limit requests:

What is the quantity requested per DAY? ______

What is the reason for exceeding the plan limitations?

Titration or loading-dose purposes

Patient is on a dose-alternating schedule (e.g., one tablet in the morning and two tablets at night, one to two tablets at bedtime)

Requested strength/dose is not commercially available

There is a medically necessary justification why the patient cannot use a higher commercially available strength to achieve the same dosage and remain within the same dosing frequency. Please specify: _______________________________

Patient requires a greater quantity for the treatment of a larger surface area [Topical applications only]

Other: ______________________________________________________________________________________

Note: If the patient exceeds the maximum FDA approved dosing of 4 grams of acetaminophen per day because he/she needs extra medication due to reasons such as going on a vacation, replacement for a stolen medication, provider changed to another medication that has acetaminophen, or provider changed the dosing of the medication that resulted in acetaminophen exceeding 4 grams per day, please have the patient’s pharmacy contact the OptumRx Pharmacy Helpdesk at (800) 788- 7871 at the time they are filling the prescription for a one-time override.

Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review?

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Please note: This request may be denied unless all required information is received.

If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. For urgent or expedited requests please call 1-800-711-4555.

This form may be used for non-urgent requests and faxed to 1-844-403-1028.

______________________________________________________________________________________________________________

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately.

Office use only: General_CMS_2019Oct-W

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part 1 to writing optumrx prior authorization form pdf 2020

Note the data in What is the patients diagnosis for, ICD Codes, What medications has the patient, What medications does the patient, Are there any supporting labs or, Use of High Risk Medications HRMs, and Does the provider acknowledge that.

Entering details in optumrx prior authorization form pdf 2020 stage 2

You may be asked to provide the information to let the application complete the field Prior Authorization Request Form, Quantity limit requests What is, bedtime, Requested strengthdose is not, Patient requires a greater, Note If the patient exceeds the, Are there any other comments, Please note, and This request may be denied unless.

Prior Authorization Request Form, Quantity limit requests What is, bedtime, Requested strengthdose is not, Patient requires a greater, Note If the patient exceeds the, Are there any other comments, Please note, and This request may be denied unless in optumrx prior authorization form pdf 2020

Please make sure to describe the rights and obligations of the parties within the This document and others if paragraph.

part 4 to filling out optumrx prior authorization form pdf 2020

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