Asthma (e 2026

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The document outlines the process for submitting a prior authorization request for Dupixent® through OptumRx in partnership with CoverMyMeds. It includes required member and provider information, medication details, clinical criteria for asthma and atopic dermatitis, and instructions for completing the form. The document emphasizes the importance of providing all necessary information to avoid denial of the request and contains confidentiality notices regarding protected health information.

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Click ‘Get Form’ to open the Asthma (e) request form in the editor.
Begin by filling out the Member Information section. Enter the Member Name, Insurance ID#, and Date of Birth. Ensure all fields are completed accurately.
Next, provide Provider Information. Input the Provider Name, NPI#, Office Phone, and Street Address along with City, State, and Zip Code.
In the Medication Information section, specify the Medication Name and Strength. Check if you are requesting a brand and fill in Directions for Use.
Proceed to Clinical Information. Select 'Asthma' as the diagnosis and complete all relevant questions regarding patient history and current treatment.
Review your entries for accuracy before submitting. Make sure all required fields are filled out to avoid delays in processing.

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