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
Question | Answer |
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Form Name | Optumrx Prior Authorization Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | optumrx prior authorization form, optumrx commercial prior authorization request form, optumrx pa forms to print, optumrx prior authorization form 2021 |
Please note: All information below is required to process this request
For urgent requests please call
For real time submission 24/7 visit www.OptumRx.com and click Health Care Professionals
OptumRx • M/S CA
Xarelto® Prior Authorization Request Form
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Member Information (required) |
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Provider Information (required) |
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Member Name: |
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Provider Name: |
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Insurance ID#: |
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NPI#: |
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Specialty: |
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Date of Birth: |
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Office Phone: |
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Medication Information (required) |
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Medication Name: |
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Strength: |
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Dosage Form: |
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Is This Medication a New Start? Yes No |
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Directions for Use: |
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Clinical Information (required) |
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Select the diagnosis below: |
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Atrial fibrillation |
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Prophylaxis of deep vein thrombosis (DVT) following hip or knee replacement surgery |
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Reduction of the risk of recurrence of DVT or pulmonary embolism (PE) |
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Treatment of DVT or PE |
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Other diagnosis: ______________________________ |
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Continuation of therapy: |
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Yes No |
Is the requested medication being used as continuation of therapy upon hospital discharge? |
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Atrial fibrillation: |
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Yes No |
Does the patient have a mechanical prosthetic heart valve? |
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Yes No |
Does the patient have a bioprosthetic heart valve? |
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Prophylaxis of DVT following hip or knee replacement surgery: |
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Yes No |
Does the patient have a completion of total knee or total hip replacement surgery? |
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Reduction in risk of recurrence of DVT or PE: |
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Yes No |
Does the patient have a previous diagnosis of DVT or PE? |
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Yes No |
Has the patient been treated with an anticoagulant for at least 6 months prior to this request? |
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Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review?
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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
This form may be used for
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Office use only: Xarelto_CMS_2014Jan.doc