______________________________________________________________________________________________________________
This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider
named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose
PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information
in this document is against the law. If you are not the intended recipient, please notify the sender immediately.
Office use only: General_UHCE&I_2016Dec-W.doc
Prior Authorization Request Form
DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED
Member Information (required)
Provider Information (required)
Medication Information
(required)
Check if requesting brand
Is the physician supplying the medication? Yes No
Continuation of therapy? Yes No
If “YES”, answer the following:
Has member been on this medication in the last 180 days?* Yes No
Does the prescriber confirm that the medication has been effective in
treating the member’s medical condition?* Yes No
Clinical Information (required)
Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses OptumRx for certain pharmacy benefit services. Your patient’s
benefit plan requires that we review certain requests for coverage with the prescribing physician. This includes requests for benefit coverage beyond plan
specifications. Please complete the following questions and then fax this form to the toll free number listed below. Upon receipt of the completed form,
prescription benefit coverage will be determined based on the benefit plan’s rules.
What is the patient’s diagnosis for the medication being requested?
____________________________________________________________________________________________________________
Please provide the medications the member has a failure, contraindication, or intolerance to:
Medication: _________________________________________
Date: ______________________
Medication: _________________________________________
Date: ______________________
Medication: _________________________________________
Date: ______________________
Medication: _________________________________________
Date: ______________________
Prescriber attestation:
Does the prescriber attest that the information provided is true and accurate to the best of their knowledge and understand
that UnitedHealthcare may perform a routine audit and request the medical information necessary to verify the accuracy of the
information provided? Yes No
Prescriber’s signature: ______________________________ Date: _________________
* May not apply to all plans
Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to
this review?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Please note: This request may be denied unless all required information is received within established timelines.
This request may be denied unless all required information is received.
For urgent or expedited requests please call 1-800-711-4555.
This form may be used for non-urgent requests and faxed to 1-800-527-0531.
Please note: All information below is required to process this request
Mon-Fri: 5am to10pm Pacific / Sat: 6am to 3pm Pacific
For real time submission 24/7 visit www.OptumRx.com and click Health Care Professionals
OptumRx • M/S CA 106-0286 • 3515 Harbor Blvd. • Costa Mesa, CA 92626
