[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283861-105":53,"doc-detail-283861-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","prior-authorization-request-form-optum-rx-and-covermymeds","Prior Authorization Request Form - Optum Rx and CoverMyMeds","","Prior Authorization Request Form for prescription benefit coverage processed via Optum Rx through CoverMyMeds. The form collects required member and provider details, medication request information, clinical questions for coverage beyond plan specifications, and documentation needs for continuation of therapy and medical rationale. It requires prescriber attestation, diagnosis coding, prior therapy failures or intolerances, and specifies fax submission timelines, with separate contact numbers for urgent or expedited requests.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/prior-authorization-request-form-optum-rx-and-covermymeds/283861/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/prior-authorization-request-form-optum-rx-and-covermymeds/283861.png","ImageObject",442,249,{"name":88,"@type":89},"Dozel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-31","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":35},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to process a prior authorization request?","Question",{"text":108,"@type":109},"The form requires member and provider details, medication request information, and clinical questions supporting coverage decisions beyond plan specifications. It also requires prescriber attestation and supporting diagnosis and prior therapy information as applicable.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How should the form be submitted?",{"text":113,"@type":109},"Complete the form and fax it to the toll-free number listed on the document. The instructions also reference urgent or expedited requests by phone within established timelines.",{"name":115,"@type":106,"acceptedAnswer":116},"When is a request considered continuation of therapy?",{"text":117,"@type":109},"The form asks whether the request is for continuation of therapy and whether medical records will be submitted. It also checks whether the member has been on the requested medication recently or is stabilized, and related effectiveness and prior treatment criteria.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283861,1790539243,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":35,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},962085662650,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Optum Rx has partnered with CoverMyMeds to receive prior authorization requests , saving you time and often delivering real-time determinations. [Visit](Visit go.covermymeds.com/OptumRx to)[ ](Visit go.covermymeds.com/OptumRx to)[go.covermymeds.com/OptumRx](Visit go.covermymeds.com/OptumRx to)[ to](Visit go.covermymeds.com/OptumRx to) begin using this free service. Please note: All information below is required to process this request.  \nMon-Fri: 5am to 10pm Pacific / Sat: 6am to 3pm Pacific  \nPrior Authorization Request Form  \nDO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED  \n\n| Member Information (required) |  |  | Provider Information (required) |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Member Name: |  |  | Provider Name: |  |  |  |\n| Insurance ID\\#: |  |  | NPI\\#: |  | Specialty: |  |\n| Date of Birth: |  |  | Office Phone: |  |  |  |\n| Street Address: |  |  | Office Fax: |  |  |  |\n| City: | State: | Zip: | Office Street Address: |  |  |  |\n| Phone: |  |  | City: | State: |  | Zip: |\n| Medication Information (required) |  |  |  |  |  |  |\n| Medication Name/Dosage Form/Strength: |  |  |  |  |  |  |\n| 􀂉 Check if requesting brand |  |  | Directions for Use: |  |  |  |\n| Clinical Information (required) |  |  |  |  |  |  |\n| Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses Optum Rx 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. |  |  |  |  |  |  |\n| Continuation of therapy*,¥ :\u003Cbr>Is this request for continuation of therapy? 􀂉 Yes 􀂉 No\u003Cbr>Will medical records be submitted documenting any of the information below? 􀂉 Yes 􀂉 No\u003Cbr>Has the member been on the requested medication in the last 180 days or is currently stabilized? 􀂉 Yes 􀂉 No Has the requested medication been safe and effective in treating the member's medical condition? 􀂉 Yes 􀂉 No\u003Cbr>Has the member tried another prescription drug in the same pharmacological class or same mechanism of action? 􀂉 Yes 􀂉 No Were prior medications discontinued due to a lack of efficacy or effectiveness, diminished effect, or an adverse event? 􀂉 Yes 􀂉 No |  |  |  |  |  |  |\n| What is the member’s diagnosis for the medication being requested?*\u003Cbr>Diagnosis:   ICD-10 Code(s):   |  |  |  |  |  |  |\n| Please provide the medications the member has a failure, contraindication, or intolerance to* :\u003Cbr>Medication:   Date of trial:   Duration of trial:   Medication:   Date of trial:   Duration of trial:   Medication:   Date of trial:   Duration of trial:   Medication:   Date of trial:   Duration of trial:   Medication:   Date of trial:   Duration of trial:   |  |  |  |  |  |  |\n| Prescriber attestation:\u003Cbr>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\u003Cbr>Prescriber’s signature:   Date:   |  |  |  |  |  |  |\n\n* May not apply to all plans  \n¥ Please note: Chart documentation of the above is required to be submitted along with this fax form  \nAre there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review?  \n________________________________________________________________________________________________________________  \n________________________________________________________________________________________________________________  \nPlease note: This request may be denied unless all required information is r","cbCaipBExc7tMTkh","https://ap.wps.com/l/cbCaipBExc7tMTkh","pdf",148057,"English","# Prior Authorization Request Form\n## Member Information\n## Provider Information\n## Medication Information\n## Clinical Information\n## Prescriber Attestation\n## Submission and Contact Information","[{\"question\":\"What information is required to process a prior authorization request?\",\"answer\":\"The form requires member and provider details, medication request information, and clinical questions supporting coverage decisions beyond plan specifications. It also requires prescriber attestation and supporting diagnosis and prior therapy information as applicable.\"},{\"question\":\"How should the form be submitted?\",\"answer\":\"Complete the form and fax it to the toll-free number listed on the document. The instructions also reference urgent or expedited requests by phone within established timelines.\"},{\"question\":\"When is a request considered continuation of therapy?\",\"answer\":\"The form asks whether the request is for continuation of therapy and whether medical records will be submitted. It also checks whether the member has been on the requested medication recently or is stabilized, and related effectiveness and prior treatment criteria.\"}]","Prior Authorization Request Form - Optum Rx and CoverMyMeds | PDF",1789620999]