Optumrx Prior Authorization Form PDF Details

Optumrx Prior Authorization Form is aMedication prior authorization is the process of getting approval from your health insurance company before you can fill a prescription for a medication. This process usually requires you to obtain a prior authorization form from your insurer, complete it, and submit it to your pharmacy. Your insurer will then review your request and determine if the medication is approved for coverage. If it is not, they may provide an alternative treatment plan or suggest that you try another medication. If you need to fill a prescription for a medication that requires prior authorization, be sure to speak with your pharmacist first. He or she can help you navigate the prior authorization process and submit the necessary paperwork to your insurance company.

This article features information about optumrx prior authorization form. There, you'll find the specifics of the PDF you want to fill out, such as the estimated time to fill it out as well as other

Form NameOptumrx Prior Authorization Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesoptumrx prior authorization form, optumrx commercial prior authorization request form, optumrx pa forms to print, optumrx prior authorization form 2021

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

Xarelto® 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












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.


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

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