Fiasp & Fiasp FlexTouch Prior Authorization Request Form (Page 1 of 2) 2026

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32 votes

The document outlines the process for submitting a prior authorization request for Fiasp® and Fiasp® FlexTouch medications through OptumRx in partnership with CoverMyMeds. It includes required member and provider information, clinical questions to determine eligibility, and instructions for submission. The form emphasizes the need for accurate information to avoid denial of requests and highlights the confidentiality of the provided data.

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Click ‘Get Form’ to open it 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 street address, city, state, and zip code.
Next, complete the 'Provider Information' section. Input the provider's name, NPI number, office phone and fax numbers, along with their address details.
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 the 'Clinical Information' section. Answer all required questions regarding therapy continuation and medication history accurately.
Finally, review all entered information for accuracy before submitting your form via fax as instructed at the bottom of the page.

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