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Click ‘Get Form’ to open the OptumRx Dupixent Prior Authorization Request Form in the editor.
Begin by filling out the 'Member Information' section. Enter the member's name, insurance ID number, date of birth, and contact details including phone and address.
Next, complete the 'Provider Information' section. Input the provider's 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 and provide directions for use.
Proceed to 'Clinical Information'. Select the appropriate diagnosis from the options provided and enter any relevant ICD-10 codes.
Answer all clinical questions regarding previous treatments and responses to ensure comprehensive information is submitted.
If applicable, complete the reauthorization questions to document any positive clinical responses to Dupixent therapy.
Review all entered information for accuracy before submitting your request through our platform.
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We will work with your doctor to get the information needed for the review. Once we receive a finished prior authorization form from your doctor, we will.Read more
Prior Authorization Request Form. DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED. Member Information(required). ProviderRead more
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