» » 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.

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