Optumrx Medication Prior Auth Form – Fill Out and Use

Eliquis® Prior Authorization Request Form

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:

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.

______________________________________________________________________________________________________________

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Office use only: Eliquis_Comm_2014Oct.doc