DO NOT COPY FOR FUTURE USE FORMS ARE - stg-prorx optum 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Member Information section. Enter the Member Name, Insurance ID#, and Date of Birth accurately.
3. Next, complete the Provider Information section. Input the Provider Name, NPI#, Office Phone, and Office Fax details.
4. In the Medication Information section, specify the Medication Name and Strength. Check if you are requesting a brand or if this is for continuation of therapy.
5. Proceed to Clinical Information. Select the appropriate diagnosis and provide ICD-10 Code(s). Answer all clinical questions regarding medication usage and patient history.
6. For Quantity limit requests, indicate the quantity requested per day and provide reasons for exceeding plan limitations if applicable.
7. Finally, review all entered information for accuracy before submitting your request through our platform.

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