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And Prior Authorization Request Form - OptumRx

And Prior Authorization Request Form - OptumRx 2025

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46 votes

The document is a Prior Authorization Request Form for the medications Provigil® and Nuvigil®, detailing required information for processing requests, including member and provider details, medication specifics, clinical information related to various diagnoses, and reauthorization questions. It emphasizes the importance of safeguarding protected health information (PHI) and provides instructions for submission.

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How to use or fill out the Prior Authorization Request Form - OptumRx

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Click ‘Get Form’ to open it in our editor.
Begin by filling out the 'Member Information' section. Enter the member's name, insurance ID number, date of birth, and contact details.
Next, complete the 'Provider Information' section with your name, NPI number, office phone, and address.
In the 'Medication Information' section, specify the medication name and strength. Indicate if you are requesting a brand version or if this is a continuation of therapy.
Proceed to the 'Clinical Information' section. Select the appropriate diagnosis and answer any related questions thoroughly.
If applicable, provide justification for any required sleep studies or previous treatments in the designated areas.
Finally, review all entered information for accuracy before submitting your request through our platform.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (176 Votes)
2015	4 Satisfied (46 Votes)
2014	4.4 Satisfied (608 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can a pharmacy request prior authorization?

If your medication requires a prior authorization, the pharmacy will notify the healthcare professional who wrote the prescription. Your prescriber will proceed to give the necessary coverage information to your insurance company.

How do I get a prior authorization for OptumRx?

Call Optum Rx at 1-844-368-8740. How long does it take for a PA to be approved or denied? Once your PA has been submitted and received, it usually takes up to 24 hours to process. If your PA request needs additional review, it may take longer.

Why is it so hard to get a prior authorization?

Steps to Obtain Prior Authorization Consult Your Doctor. Start by discussing your treatment plan and any specific medications your provider recommends. Contact Your Insurance Provider. Call your insurance company or log into their online portal to check if prior authorization is required. Submit the Request. Await Approval.

How do I submit a prior authorization to OptumRx?

Call Optum Rx at 1-844-368-8740. What do I do if my medication needs a PA? To begin the PA process, you can: Let your doctor know that a PA is needed for your medication. Call Optum Rx at 1-844-368-8740.

How to get a prior authorization form?

To receive coverage for a medication requiring prior authorization, you can: Ask your healthcare provider to submit the request. Your healthcare provider can submit the request online, by fax or phone by accessing our providers prior authorization information. Submit your own prior authorization request.

How to obtain prior authorization?

How To Get Prior Authorization: Step-by-Step Guide Step 1: Check client eligibility. Step 2: Determine if a code or service requires Prior Authorization. Step 3: Find and complete forms. Step 4: Submit a PA request. Step 5: Check the status of an authorization.

And Prior Authorization Request Form - OptumRx 2025

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How to use or fill out the Prior Authorization Request Form - OptumRx