Prior Authorization Request Form – Fill Out and Use This PDF

The Prior Authorization Request form is an essential document for healthcare providers to secure approval from a patient's insurance company before prescribing or administering certain medications or treatments. It collects comprehensive information including patient details, provider information, and medication specifics to facilitate a coverage determination request by OptumRx. To ensure your patients receive the necessary medications without delay, fill out and submit the form by clicking the button below.

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Prior Authorization Request Form PDF Details

Embarking on the journey of obtaining necessary medications through insurance can often be a complex process, one that frequently involves the completion of a Prior Authorization Request form. This form serves as a pivotal piece of documentation, facilitating communication between healthcare providers and insurance companies. It encompasses not only the patient’s basic information, including name, insurance ID, and contact details but also extends to include intricate details regarding the prescribed medication such as dosage, diagnosis, ICD-9 codes, and specific instructions for use. Additionally, the form delves into the patient’s medical history, asking whether previous medications have been attempted and failed, thus substantiating the need for the requested medication. For medications that are particularly specialized, such as those for rheumatoid arthritis, psoriasis, Crohn’s disease, or other conditions, the form requests detailed information on symptom severity, past treatments, and any potential contraindications. The Prior Authorization Request form is more than just paperwork; it is a critical tool designed to ensure patients receive the best possible care, tailoring medication choices to each individual's unique health scenario while navigating the complexities of insurance coverage. By adequately completing and submitting this form, healthcare providers advocate for their patients’ needs, striving towards optimizing treatment outcomes.

Question	Answer
Form Name	Prior Authorization Request Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	optumrx prior auth printable form, optumrx prior authorization request form to print, optumrx medication prior authorization form, optumrx prior authorization request form

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Prior Authorization Request Form

Fax Back To: 1-800-853-3844

Phone: 1-800-711-4555

5 AM – 7 PM PST M-F

Prior Authorization Form

Patient Information

Patient’s Name:

Insurance ID:	Date of Birth:	Height:		Weight:
Address:		Apartment #:
City:	State:	Zip:
Phone Number:	Alternate Phone:	Sex:	Male	Female
Provider Information
Provider’s Name:	Provider ID Number:
Address:	City:	State:		Zip:
Suite Number:	Building Number:
Phone Number:	Fax number:
Provider’s Specialty:
Medication Information
Medication:	Quantity:	ICD9 Code:
Directions:	Diagnosis:	Refills:
Will the physician supply this medication?		Yes	No

By providing the information it will only be used for coverage determination request administered by OptumRx.

Medication Instructions

Has the patient been instructed on how to Self-Administer?		Yes	No
Is this medication a New Start?		Yes	No
If NO please provide the following:	Initiation Date: / /	Date of Last Dose: / /

This is to notify you that your patient’s request for this medication may be denied unless we receive supportive information, i.e., medications tried and failed, document improvement with medication(s). Please provide information to support this request. Please fax back at the number listed above or call at 1-800-711-4555.

Administration Instructions

Dispensing Location: Physician’s Office

Patient’s Address

Date medication is needed: / /

Medication Administered: Home Health Self Administered LTC Physician’s Office

*If you have any questions regarding your patient’s plan drug limits you may call us at: 1-800-711-4555.

______________________________________________________________________________________________________________

This electronic fax transmission, including any attachments contains information from OptumRx that may be confidential and/or privileged. The information contained in this facsimile is intended to be for the sole use of the individual(s) or entity named above. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information is strictly prohibited by law and will be vigorously prosecuted. If you have received this electronic fax transmission in error, please notify the sender immediately and return the document(s) by mail to OptumRx Privacy Office, 2300 Main St., M/S CA134-0501, Irvine, CA 92614 www.optumrx.com BlankSpecialtyForm_Jan2013.doc

Enbrel-Humira-Remicade-Orencia-Kineret-Simponi-Cimzia-Actemra-Stelara

Patients Name: ___________________________________________

Patients ID#: ____________________ DOB: ___________________

OptumRx Specialty Prior Authorization (continued)

OptumRx

Fax # 1-800-853-3844

Page 2 of 2

Document the patient’s diagnosis: ______________________________ ICD-9 Code: _________________

_____________________________________________________________________________________________________________________

Please Document all that applies to the Patient

Has the patient been evaluated for tuberculosis and treated accordingly?	Yes		No
Document date of last PPD test: _________	Negative		Positive

For Diagnosis of Rheumatoid Arthritis or Ulcerative Colitis: Does the Patient exhibit symptoms of MODERATE to SEVERE?

Yes No

For Diagnosis of Psoriasis: Does the patient have failure, intolerance or contraindication to: (Please circle all that apply) Ultraviolet Light B (UVB), Pulsed Dye Laser, Photochemotherapy, Psoralen and exposure to Ultraviolet light a (PUVA)


For Diagnosis of Crohn’s Disease: Does the patient exhibit symptoms of MODERATE to SEVERE?		Yes	No
Has induction dose been prescribed? Yes	No (if NO document reason why it has not been prescribed)

_____________________________________________________________________________________________________________

Document if the patient has tried, failed or had contraindication

Methotrexate

Imuran (azathioprine)

Cyclosporine (Sandimmune, Neoral)

Gold compounds (Myochrisine, Ridura, Aurolate, and Solganal) Plaquenil (hydroxychloroquine)

Arava (leflonomide) Cuprimine (penicillamine)

Aminosalicylates (e.g. sulfasalazine, azulfidine, mesalamine)

6-mercaptopurine (Purnethol) NSAIDs (e.g. Ibuprofen)

6-thioguanine Acitretin (soriatane) Hydroxyurea (hydrea) Mycophenolate (cellcept) Corticosteroids

Please Document Dates of therapies for medications selected: __________________________________

Please document any clinical contraindications to these medications:_______________________________________________________

______________________________________________________________________________________________________________

Has the patient had a trial, failure or contraindication to any of the following medications? (Please list dosage and/or contraindication)

Enbrel®	Yes	No	Dosage / Contraindication
			_________________________
Humira®	Yes	No	_________________________

Remicaid®	Yes	No	_________________________

Orencia®	Yes	No	_________________________
Kineret®	Yes	No	_________________________
Simponi®	Yes	No	_________________________

Cimzia®	Yes	No	_________________________

Actemra®	Yes	No	_________________________
Stelara®	Yes	No	_________________________

____________________________________________________________________________________________________________

Continuation of Therapy

Has the patient utilized the medication in the past 45 days?	Yes	No
Has the patient had documented clinical improvement from ongoing therapy?	Yes	No

(Please document dose reduction or reason for high dose [if applicable])

*If the above information is not available, please attach the patient’s chart notes documenting clinical improvement.

*If you have any questions regarding your patient’s plan drug limits you may call us at: 1-800-711-4555.

For UHC members: Your patient’s prescription benefit requires that we review certain requests for coverage with the prescriber. You have prescribed a medication for your patient that requires Prior Authorization before benefit coverage can be provided. Please complete the following questions then fax this form to the toll free number listed below. Upon receipt of the completed form, prescription benefit coverage will be determined based on the plan’s rules

______________________________________________________________________________________________________________

Main St., M/S CA134-0501, Irvine, CA 92614 www.optumrx.com Enbrel-Humira-Kineret-Orencia-Remicade-Simponi-Cimzia-Actemra- Stelara_2012June.doc

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Filling out segment 1 in optumrx prior authorization form

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Prior Authorization Request Form – Fill Out and Use This PDF

Prior Authorization Request Form PDF Details

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