» » OptumRx Prior (Rx) Authorization Form

OptumRx Prior (Rx) Authorization Form

When a physician wishes to prescribe a non-recommended medication for an OptumRx member, they will have to request coverage by filling and faxing an OptumRx Prior Authorization Form. Below you will find the fax number which you should fax the form to, and a phone contact should you require immediate assistance. For medical services, use the OptumCare Prior Authorization Form which is found here.

How to Write

Step 1 – Begin by filling providing the patient’s name, insurance ID number, date of birth, complete address, and phone number into the Member Information section.

Step 2 – In Provider Information, enter your name, your NPI number, your specialty, your office phone and fax number, and the complete address of your office.

Step 3 – In Medication Information, enter the name, strength, form of dosage, and directions for use of the medication you are requesting coverage for. Next, indicate whether you are requesting a particular brand of drug, whether this is a continuing prescription, and if so, whether the medication has been effective.

Step 4 – Then enter the relevant diagnosis that you have made of the patient into the indicated field. Below that, provide the types and duration of use for any previous medications that your patient has been prescribed for this diagnosis.

Step 5 – Finally, you must attest to the verity of your submitted information, provide your signature, and the date.

Step 6 – If you have any other comments that you would like to be considered, enter them into the indicated area near the bottom of the form.



Related pages


land rental agreement templatewisconsin rental agreementtd direct deposit form onlinerental contract template freenc dmv form mvr 1deed of release missourisalon booth rental agreement templategrazing lease formreal estate power of attorney templatesouth carolina notary formvacate letter to landlordhow to write an eviction notice to renternavy federal routing number scrouting number for capital one bank louisianasample late rent notice letterlease agreement template pdffillable invoice templateteaching resignation letternotary forms floridarenter eviction notice formeviction notice in missourilease agreement alabamaautomobile bill of sale pdfspecial warranty deed templatequit claim deed form mnsimple credit card authorization formfree downloadable living will formsquit claim deed coloradoeviction in new yorkpromissory note arizonasouth dakota handgun lawsoklahoma vehicle title transferoklahoma rental agreementlease purchase option agreement formdurable general power of attorney new yorknys health care proxyreceipt for rent depositinvoice template word free downloadpaychex direct deposit change formkentucky tenant lawslease option agreement formtriple net lease exampletemporary guardianship in oklahomasample subleaselandlord lease termination letter sampletermination letter template freeohio bmv forms power of attorneynorth carolina eviction processadvance directive form marylandunsecured loan agreement individual to companyeviction notice washington statekauai county dmvpromissory note draftsamples of letter of recommendation for a friendexample of an eviction noticetermination letter sample californiaeviction illinoistaa lease formwyoming llc operating agreementmo dept of revenue bill of saleroofing invoicellc operating agreement illinoisexample and template for personal or character reference letterflorida auto bill of sale formexpress scripts prior authorizationhow to write a promisary notecommercial invoice fedex templatemichigan eviction lawdeed of trust templatenotice to quit paillinois llc registrationhawaii probate codemaricopa recorded documentsnavy federal cu addresskauai vehicle registrationblank quit claim deedspecial warranty deed pennsylvania