Optumrx Medication Prior Auth Form PDF Details

Optumrx medication prior auth form is a document that is used to request authorization for the patient's prescription drug benefits. The form is usually used when the patient's insurance plan does not cover the cost of their medication. Depending on the insurance company, there may be specific requirements that must be met in order for the prior auth form to be approved. The purpose of this blog post is to provide an overview of the Optumrx medication prior auth form, and to outline some of the most common requirements that are typically requested by insurance companies.

Below is the information about the form you were seeking to complete. It can tell you the time it takes to complete optumrx medication prior auth form, exactly what fields you will need to fill in and a few other specific facts.

Form NameOptumrx Medication Prior Auth Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesoptumrx prior auth form 2021, optumrx prior authorization, optumrx prior authorization request form, optumrx prior auth

Form Preview Example


Please note: All information below is required to process this request For urgent requests please call 1-800-711-4555 Mon-Fri: 5am to10pm Pacific / Sat: 6am to 3pm Pacific

For real time submission 24/7 visit www.OptumRx.com and click Health Care Professionals OptumRx • M/S CA 106-0286 • 3515 Harbor Blvd. • Costa Mesa, CA 92626

Eliquis® Prior Authorization Request Form


Member Information (required)



Provider Information (required)





















Member Name:






Provider Name:



















Insurance ID#:
























Date of Birth:






Office Phone:




















Street Address:






Office Fax:



























Office Street Address:













































Medication Information (required)

















Medication Name:








Dosage Form:













Is This Medication a New Start? Yes No





Directions for Use:





















Clinical Information (required)


















Select the diagnosis below:












Atrial fibrillation (AF)













Prophylaxis of venous thromboembolism (VTE) after orthopedic surgery






Reduction in the risk of recurrence of deep vein thrombosis (DVT) or pulmonary embolism (PE)





Treatment of DVT or PE












Other diagnosis: ______________________________

ICD-9/10 Code(s): _____________________________________

Continuation of therapy:

Yes No Is the requested medication being used as continuation of therapy upon hospital discharge?

Atrial fibrillation:

Yes No Does the patient have a bioprosthetic heart valve?

Yes No Does the patient have a mechanical prosthetic heart valve?

Prophylaxis of VTE after orthopedic surgery:

Yes No Does the patient have a completion of total knee or total hip replacement surgery?

Reduction in the risk of recurrence of DVT or PE:

Yes No Does the patient have a previous diagnosis of DVT or PE?

Yes No Has the patient been treated with an anticoagulant [e.g. warfarin, Pradaxa (dabigatran), Eliquis (apixaban), Xarelto (rivaroxaban)] for at least 3 months prior to this request?

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

Other: _________________________________________________________________________

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 1-800-527-0531.


This document and others if attached contain information from OptumRx that is privileged, confidential and/or may contain protected health information (PHI). We are required to safeguard PHI by applicable law. The information in this document is for the sole use of the person(s) or company named above. 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 and return the document(s) by mail to OptumRx Privacy Office, 17900 Von Karman, M/S CA016-0101, Irvine, CA 92614. www.optumrx.com

Office use only: Eliquis_Comm_2014Oct.doc

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