We offer other various resources to help support your understanding and use of ePA. Step 3: Click the Done button to save the file. Authorization form - English PDF Formulario Estndar de Autorizacin para la Divulgacin de Informacin de Salud Protegida (PHI) (Espaol) Usamos este formulario para obtener su consentimiento por escrito para divulgar su informacin de salud protegida (protected health information, PHI) a alguien que usted haya designado. Arizona: Commercial Prescription Prior Authorization Form for Prescription Drug, DME-Medical Devices . Un Representante Personal puede ser legalmente designado o nombrado por el miembro o el paciente para actuar en su nombre. 17 January, 2018 Introduction to OptumRx. Fax Number: 1-844-403-1028 Prior Authorization Department . 16 0 obj Submit a prior authorization; Utilization management changes, effective 01/01/23; DPL Main Nav Items . As part of an ongoing effort to increase security, accuracy, and timeliness of PA Follow the instructions below to fill out Optumrx tier exception form online quickly and easily: <>stream uuid:57a4631a-2f5b-460a-a79e-d6d5b547b995 Electronic payment solutions; FAQs; Fraud, waste, abuse and general compliance; Forms; Formulary and updates; Guides, manuals and training; Notices; Payer sheets; See all; DPL Main Nav Items. 1-855-427-4682. Open the email you received with the documents that need signing. %PDF-1.5 Improving efficiencies without sacrificing the essentials, Three Easy steps to completing requests electronically. Download now. Create your signature, and apply it to the page. How it works Upload the optumrx prior authorization form 2022 Edit & sign optumrx prior auth form 2022 pdf from anywhere Save your changes and share optumrx prior auth form 2022 Rate the optumrx prior auth form 4.8 Satisfied 93 votes be ready to get more Create this form in 5 minutes or less Get Form This request does not allow your designated person to make any of your treatment decisions or direct care decisions. Please complete all pages to avoid a delay in our decision. `HJsCiG:!HY5VX1rAZvdZ Open PDF, opens in a new tab or window. PAs help manage costs, control misuse, and Your patients This will require the following: Step 4 The medications name, strength and dosage form must be enter next. No phone trees. <> OptumRx Prior Authorization Guidelines and Procedures That's why we have a team of experts and a variety of help resources to make requests faster and easier. OptumRx, except for the following states: MA, RI, SC, and TX. hVn8>X$I"(8qhEnDX2$I~P-;v4pf4s52tL0 BLI`VL Y3(9d6sa$@9t!Xu! requests and determinations, OptumRx is retiring most fax numbers used for Find OptumRx formularies, formulary updates . DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. OptumRx's Preferred Method for Prior Authorization Requests Our electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible. All you have to do is download it or send it via email. hb``b``*`bd1! 2016-09-16T07:22:50.000-05:00 141 0 obj Refer to the Support section or contact our Support crew in the event that you have any concerns. hbbd```b``[A$;fGH."Y@${8 "Y&(H RKD2DH`vdowmybefbC>10120>8B ) A Personal Representative may be legally appointed or designated by the member or patient to act on their behalf. Click on New Document and select the form importing option: upload Optumrx prior authorization form pdf 2021 from your device, the cloud, or a protected link. Open PDF, . Double check all the fillable fields to ensure complete accuracy. <>/Metadata 3 0 R/Pages 136 0 R/StructTreeRoot 7 0 R/Type/Catalog/ViewerPreferences 159 0 R>> O4 Footer Nav. endobj If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against . 12 0 obj Prior authorization form. Utilize a check mark to point the choice wherever required. Press Done after you fill out the blank. endstream endobj 343 0 obj <>/Metadata 15 0 R/Names 372 0 R/Pages 339 0 R/StructTreeRoot 33 0 R/Type/Catalog/ViewerPreferences 373 0 R>> endobj 344 0 obj <>/MediaBox[0 0 612 792]/Parent 339 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 345 0 obj <>stream Injectable Psychotropic - Optum. the OptumRx UM Program. Submitting a PA request Did you know Over 2/3 of the PAs that we receive each year are now electronic. This form may be used for non-urgent requests and faxed to 1-800-527-0531. Select the area you want to sign and click. If the patient is not able to meet the above standard prior authorization requirements, please call 1-800 -711 -4555. Our site is the place to go if you want to edit and acquire this form. 140 0 obj ", Arkansas Prior Authorization or Exception Request, Online Claim Form: UHG, Medicare, PDP, MAPD, Commercial, PPO, Union and Others, Claim Form Medicare Part D Frequently Asked Questions English, Claim Form Medicare Part D Frequently Asked Questions Spanish, Claim Form: UHG, Medicare, PDP, MAPD, Commercial, PPO, Union and Others. Optimal. <> All Rights Reserved. Start a Prior Authorization with CoverMyMeds > Prior Authorization Form Mavyret This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). therapy and non-formulary exception requests. ee` fd Click thislinkto leverage theAMA's video seriesto educate your staff about the advantages of ePA. endobj dates and more. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline OptumRx is not authorized to review requests for medications supplied by the physicians office. HWn8}WiIJAdu$,d(j[~V&nge^U9UV ^<. Create an account using your email or sign in via Google or Facebook. <>/MediaBox[0 0 612 792]/Parent 136 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> Utilization management updates . DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. 2 0 obj Enter their name, insurance ID number, DOB, full address, and phone number. Open PDF, opens in a new tab or window. Optum Prior Authorization Criteria Specific Forms. Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE. 1 0 obj Prior Authorization Request Form Please complete this entire form and fax it to: 866-940-7328. Formulario Estndar de Autorizacin para la Divulgacin de Informacin de Salud Protegida (PHI) (Espaol) %PDF-1.7 % Decide on what kind of signature to create. OptumRX Prior Prescription Authorization Form Step 2 - The first required information is that of the member. % Send filled & signed optiumrx or save. Prior Prescription (RX) Authorization Forms, OptumRX Prior Prescription (Rx) Authorization Form, CVS Prior Prescription (Rx) Authorization Form, CIGNA Prior Prescription (Rx) Authorization Form, Future Scripts Prior Prescription (Rx) Authorization Form, Meridian Prior Prescription (Rx) Authorization Form, Amerigroup Prior Prescription (Rx) Authorization Form, EnvisionRX Prior Prescription (Rx) Authorization Form, Humana Prior Prescription (Rx) Authorization Form, Harvard Pilgrim Healthcare Prior Prescription (Rx) Authorization Form, Authorization Forms Adobe PDF and Microsoft Word. Now you'll be able to print, download, or share the document. For requests for buy and bill, please contact the patients medical benefit. endobj Get Form Now Download PDF Optumrx Prior Authorization Form PDF Details If you cannot submit requests to the OptumRx PA department through ePA or telephone,click here. Box 25183 . The American Medical Association (AMA) wants to help bring ePA awareness to physician practices. Optumrx Prior Authorization Appeal Form 2019-2023 Use a go covermymeds optumrx 2019 template to make your document workflow more streamlined. 0 Sign in to the editor with your credentials or click Create free account to evaluate the tool's features. encourage providers to submit PA requests using the ePA process as described Proper consent to disclose PHI between these parties has been obtained. Author: Miley, David T Created Date: 12/23/2022 9:56:07 AM . IME: Prior Authorization Form Tips. <> V3`#lK2m%\ekvNYN9(^,4b"wx?_y=X]>d''x7|{rO0slTZcL(A$9cOij&KM?|PW( ~?: ,5/V!}=#Y:w53~))$VS|4Bq")rUj7nN'7C|v C*rMFDMdb)y]E*DJc 05ZAk YyY_4NdEsAk^OI"@D_ 02 Add the PDF you want to work with using your camera or cloud storage by clicking on the. We know PA requests are complex. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . Take advantage of the top and left-side panel tools to redact Optumrx prior authorization form pdf 2021. 4 0 obj Submitting a PA request Did you know Over 2/3 of the PAs that we receive each year are now electronic. If you are new to electronic prior authorizations (ePA), here are a few benefits to consider: Saves time: Providers who report using ePA submissions on average spend 2.5 fewer hours on PAs per week*, Provides real-time submissions with typical resolutions in less than 5 minutes at no additional cost, Eliminates wait time on the phone or using manual fax forms, Reduces disruptions to patient care, Allows renewals to be created from previous submissions, Includes specific clinical questions pertinent to patient plan requirements, Reduces paperwork: Process is eco-friendly, Protects patient health information: Provides secure transmission using the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard, Save time today and submit your PA requests to OptumRx through any of the following online portals:**. Microsoft Word 2010 $&`vi RHw2e`. Use the Sign Tool to add and create your electronic signature to signNow the Optimal prior authorization form. P.O. The PDF form you wish to fill out will contain the next areas: Jot down the data in ICD, Codes. Member Information Prescriber Information Member Name: Provider Name . PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Search for the document you need to electronically sign on your device and upload it. O4 1 Column (Full) O4 Text Component. O4 Footer. %%EOF Usamos este formulario para obtener su consentimiento por escrito para divulgar su informacin de salud protegida (protected health information, PHI) a alguien que usted haya designado. See buprenorphine/naloxone tab prior authorization criteria Our electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible. endobj **The ePA solution supports all forms of PA and formulary exception requests. We work with. It enables a faster turnaround time of coverage determinations for most PA types and reasons. allowed by state or federal law. Please note: All information below is required to process this request 374 0 obj Open PDF, opens in a new tab or window. uuid:94c837f8-2907-48ac-b6be-ad7166d0dcfe application/pdf Super Fast Download Medicaid Prior Authorization video HD Youtube HD. (Hours: 5am PST to 10pm PST, Monday through Friday. O4 2 Columns (1/2 - 1/2) O4 Text Component. Use the Sign Tool to add and create your electronic signature to signNow the Prior Authorization Request Form Member . protect patient safety, as well as ensure the best possible therapeutic outcomes. The following January 1, 2023 flyers are sent to members to outline the drugs affected by prior authorization, quantity limits, and step therapy based on benefit plan designs. For urgent or expedited requests please call 1-800 -711 -4555. 8X R@, f`\iW sXXNe`pj! <>/Filter/FlateDecode/ID[]/Index[138 56]/Info 137 0 R/Length 102/Prev 122747/Root 139 0 R/Size 194/Type/XRef/W[1 3 1]>>stream optumrx appeal form pdf. endobj OptumRx is not authorized to review requests for medications supplied by the physicians office. OptumRx Prior Authorization Health care professionals website Prior authorization for prescribers Prior authorizations (PAs) help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. Over 2/3 of the PAs that we receive each year are now electronic. OptumRx Prior Authorization Health care professionals website Prior authorization for prescribers Prior authorizations (PAs) help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. Submitting prior authorizations via ePA (electronic prior authorization) is the fastest and most convenient method for submitting prior authorizations. <>/Metadata 398 0 R/Pages 192 0 R/StructTreeRoot 12 0 R/Type/Catalog>> Personal Representative form - English PDF. Some medications must be reviewed because . These rights are collectively known as Individual Rights. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Exclusions may include cost reduction requests such as tiering exception, copay waiver, and tier cost sharing.To submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., HCR), please contact the OptumRx PA department through For medications not listed on this form, please refer to our partners at . Open PDF, opens in a new tab or window. OptumRx New Prescription Physician Fax Download - Medicaid Prior Authorization video, BNK.WIKI. Optum Prior Authorization Criteria Specific Forms Injectable Psychotropic - Optum Open PDF Neuromuscular - Optum - Achalasia, Chronic Anal Fissure, Detrusor Overactivity, Spasticity, Bleopharospasm Open PDF Neuromuscular - Optum - Migraine, Cervical Dystonia, Overactive Bladder Open PDF RSV- Optum Open PDF reason prescribed before they can be covered. endobj En el caso de los Representantes Personales que hayan sido legalmente designados, pueden llenar este formulario y adjuntar documentacin legal de respaldo, tales como un Poder que indique la autoridad total para tomar decisiones sobre la atencin de la salud, documentacin de la tutela, etc. endobj 138 0 obj Use este formulario para dar su consentimiento para la divulgacin de la informacin de salud protegida tanto verbal como escrita, que incluye su perfil o registro de recetas, a la persona que usted haya designado en el formulario. OptumRX Prior Prescription Authorization Form. For requests for buy and bill, please contact the patients medical benefit. 196 0 obj prior authorization (PA), to ensure that they are medically necessary and appropriate for the Go to the Chrome Web Store and add the signNow extension to your browser. Select the area where you want to insert your signature and then draw it in the popup window. 2016-12-02T11:43:26.719-06:00 You can submit a verbal PA request. Supply the diagnosis followed by a list of medications that have been tried and failed and the date on which each drug was prescribed. QA7"/>-[x/*nt{]1a=RpLp|7{-6NxfO_Zk~[Z`M'h]|^whH}v;vlnk~ ]W{AlB:2Gt!mxzG qa>OW=PIvCqX ^ 4e*Y wo.Hp^?.Mo\||>^3u{-dth"dhxBg?;JLu &i/ncQ7ADjZ wFrv. endobj Get access to thousands of forms. Draw your signature or initials, place it in the corresponding field and save the changes. <> In the Prior, Authorization, Request, Form, Page, of bedtime, and Please, note area, highlight the important data. Click the New Document option above, then drag and . (f` pe%TfVAXY.K3`(o]"_0q_fb`` That's why we have a team of experts and a variety of help resources to make requests faster and easier. As an OptumRx provider, you know that certain medications require approval, or endobj endobj Guidelines are based on written objective pharmaceutical UM decision- 2016-12-02T11:43:26.506-06:00 It has significantly reduced the paperwork burden of my office and office staff as far as prior authorizations go. Other ways to submit a prior authorization, Having difficulties with ePA? Top. Click here to view the OptumRx PA guidelines and Exception Request Procedures. <> Access the providers' prior authorization form to seek approval to prescribe medications for your patients. [292 0 R 293 0 R 294 0 R 295 0 R 296 0 R 297 0 R 298 0 R 299 0 R 300 0 R 301 0 R 302 0 R 303 0 R 304 0 R 305 0 R 306 0 R 307 0 R 308 0 R 309 0 R 310 0 R 311 0 R 312 0 R 314 0 R 315 0 R 316 0 R 313 0 R 373 0 R 317 0 R 318 0 R 319 0 R 320 0 R 321 0 R 322 0 R 323 0 R 324 0 R 325 0 R 326 0 R 327 0 R 328 0 R 329 0 R 330 0 R 331 0 R 332 0 R 333 0 R 334 0 R 335 0 R 336 0 R 337 0 R] 139 0 obj Miley, David T The Provider named above is required to safeguard PHI by applicable law. 290 0 obj FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED . Specialty drugs typically require a prior authorization. Formulario de autorizacin - PDF en espaol. these guidelines may not apply. We recommend you speak with your patient regarding review decisions on sound clinical evidence and make a determination within the timeframe TheOptumRX Prior Authorization Request Formis a simple form to be filled out by the prescriber that requests that a certain treatment or medication be covered for a patient. 3 0 obj %%EOF <> <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 15 0 R 16 0 R 17 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R 41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R 49 0 R 50 0 R 51 0 R 52 0 R 53 0 R 54 0 R 55 0 R 56 0 R 57 0 R 58 0 R 59 0 R 60 0 R 61 0 R 62 0 R 63 0 R 64 0 R 65 0 R 66 0 R 67 0 R 68 0 R 69 0 R 70 0 R 71 0 R 72 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Fax the form, once 100% complete, to1 (800) 711-4555 if this is an expedited request, or to1 (800) 527-0531 if the need for the medication could be classified as non-urgent. If you cannot submit requests to the OptumRx PA department through ePA or telephone,click here. Show details How it works Open the covermymeds prior authorization form pdf and follow the instructions Easily sign the covermymeds optumrx with your finger 342 0 obj <> endobj 17 0 obj Enter their name, insurance ID number, DOB, full address, and phone number. telephone or fax. 2 - Express Scripts data on file, 2019. If you are new to electronic prior authorizations (ePA), here are a few benefits to consider: Saves time: Providers who report using ePA submissions on average spend 2.5 fewer hours on PAs per week*, Provides real-time submissions with typical resolutions in less than 5 minutes at no additional cost, Eliminates wait time on the phone or using manual fax forms, Reduces disruptions to patient care, Allows renewals to be created from previous submissions, Includes specific clinical questions pertinent to patient plan requirements, Reduces paperwork: Process is eco-friendly, Protects patient health information: Provides secure transmission using the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard, Save time today and submit your PA requests to OptumRx through any of the following online portals:**. manner, please submit all information needed to make a decision. 13 0 obj This info will allow those at OptumRX to determine whether or not partial or full coverage is feasible. The best way to edit Optumrx tier exception form in PDF format online 9.5 Ease of Setup DocHub User Ratings on G2 9.0 Ease of Use DocHub User Ratings on G2 Handling paperwork with our comprehensive and intuitive PDF editor is straightforward. Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. If denied, the provider may choose to prescribe a less costly but equally effective, alternative Follow the Support section or get in touch with our Support team in the event that you have got any concerns. 14 0 obj A list of tried and failed medication must be provided as a justification for the request alongside the diagnosis. Step 3 Next, to the right of the member info, supply the healthcare provider info. Open the doc and select the page that needs to be signed. Microsoft Word 2010 The information in this document is for the sole use of OptumRx. signNow makes signing easier and more convenient since it provides users with a range of additional features like Invite to Sign, Add Fields, Merge Documents, and many others. Please contact the OptumRx Prior Authorization department at 1-800-711-4555 or . Any device can be used, such as a phone, tablet, or laptop. This form may contain multiple pages. <>stream Provider named above is required to safeguard PHI by applicable law. Press Done after you finish the blank. your Dashboard to submit your PA request. if it will be covered under your pharmacy benefit. above. OptumRx has partnered with CoverMyMeds to receive prior authorization requests, . endobj After that, your optimal prior authorization form is ready. Miley, David T <>/MediaBox[0 0 612 792]/Parent 192 0 R/Resources<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 0/Tabs/W/Type/Page>> Install the signNow application on your iOS device. endobj Submitting an electronic prior authorization (ePA) request to OptumRx For urgent or expedited requests please call 1-800-711-4555. stream We strongly This form may be used for non-urgent requests and faxed to 1-800-527-0531. coverage determinations for most PA types and reasons. Step 2 The first required information is that of the member. hb```g``fa`e`X}A@,3.Y600Ix^ ` . endobj ' @}\,@:uX AS ~ - Esta solicitud no permite que esta persona tome decisiones sobre su tratamiento ni decisiones directas sobre la atencin de la salud. O4 Footer Nav Items. Step 1 - Begin by downloading the form in Adobe PDF and opening it up in the PDF reader of your choice. ), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. OptumRx Prior Authorization and Exception Request Procedures Submitting an electronic prior authorization (ePA) request to OptumRx ePA is a secure and easy method for submitting,managing, tracking PAs, step therapy and non-formulary exception requests. endstream h}]ui#gVmv. 193 0 obj Enter in the date and, once the document has been printed off, sign the signature field. Over 2/3 of the PAs that we receive each year are now electronic. Patients. ePA can save time for you and your staff, leaving more time to focus on patient care. Create this form in 5 minutes! y?S} T Make adjustments to the template. July 1, 2022. Step 6 Check the yes box to indicate that all the information provided is both true and accurate. You may also ask us for a coverage determination by calling the member services number on the back of your ID card. Easily sign the optumrx prior authorization form 2022 with your finger. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. 370 0 obj <>/Filter/FlateDecode/ID[<6A51065327B04A46813B4732261321B1>]/Index[342 73]/Info 341 0 R/Length 135/Prev 314608/Root 343 0 R/Size 415/Type/XRef/W[1 3 1]>>stream Dermatology. This form may be sent to us by mail or fax: Address: OptumRx . If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request . For more information on HIPAA individual rights, click here. making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. ePA is a secure and easy method for submitting,managing, tracking PAs, step Providers. Open PDF, . The advanced tools of the editor will lead you through the editable PDF template. <> To exercise your rights under HIPAA, click here. the decision-making process and may result in a denial unless all required information is received. Prior authorizations (PAs) help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. OptumRx Prior Authorization Form is a great way to get the drugs you need. 0 The information inthis document isfor the sole use of OptumRx. Please review each document for more details. endobj There are three variants; a typed, drawn or uploaded signature. Click here to view the OptumRx PA guidelines and Exception Request Procedures. Start a Request Scroll To Learn More Why CoverMyMeds We offer other various resources to help support your understanding and use of ePA. Created Date: 10/19/2020 8:48:26 AM . **The ePA solution supports all forms of PA and formulary exception requests. See buprenorphine/naloxone tab prior authorization criteria Additionally, a documented allergy to inactive ingredient in preferred product that is not in requested product 12/3mg: 1/day 8/2mg: 2/day 4/1mg: 2/day 2/0.5mg: 3/day ^ Zubsolv NP . Use professional pre-built templates to fill in and sign documents online faster. Loginto your preferred web-based portal account and select New Requestwithin I have been using this service since last year and it simply gets better and better. 752dc44aac14d1f9c79b428b5625173e746a1557 %PDF-1.7 % Now you'll be able to print, download, or share the document. endobj Step 1 Begin by downloading the form in Adobe PDF and opening it up in the PDF reader of your choice. Who May Make a Request: Verify your NPI to receive all requests initiated at your patients pharmacies, Use your account to initiate, access and submit requests, HIPAA compliant and available for all plans and all medications. See the ePA Video Overview below to learn more. This form must be completed in full and double checked for accuracy before being faxed to the insurance company for review. telephone or fax. Now you may print, download, or share the form. We know PA requests are complex. <> Optum Prior Authorization Criteria Specific Forms. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior

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