Optumrx Prior Authorization Form – Fill Out and Use

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

Xarelto® 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

 Prophylaxis of deep vein thrombosis (DVT) following hip or knee replacement surgery

 Reduction of the risk of recurrence of 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 mechanical prosthetic heart valve?

 Yes  No

Does the patient have a bioprosthetic heart valve?

Prophylaxis of DVT following hip or knee replacement surgery:

 Yes  No

Does the patient have a completion of total knee or total hip replacement surgery?

Reduction in 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 for at least 6 months prior to this request?

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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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: Xarelto_CMS_2014Jan.doc