Prior Authorization Request Form - Page 1 of 2 - Medication and Clinical Information

Sep 17, 2026

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Prior Authorization Request Form (Page 1 of 2) for submitting required member, provider, and medication details to support coverage determinations. The form collects member identifiers, date of birth, address and contact information, plus provider name, NPI, specialty, and office contact details. It captures medication name, dosage form, strength, brand/continuation checkboxes, and clinical justification including ICD-10 diagnosis codes, prior therapies with trial details, contraindications or intolerances, supporting labs, and quantity limit request rationale.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Member Information (required)

Provider Information (required)

Medication Information (required)

Clinical Information (required)

Quantity limit requests

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Member Information (required) | | |
Provider Information (required) | | | | | --- | --- | --- | --- | --- | --- | --- | | Member Name: | | | Provider Name: | | | | | Insurance ID\#: | | | NPI\#: | | Specialty: | | | Date of Birth: | | | Office Phone: | | | | | Street Address: | | | Office Fax: | | | | | City: | State: | Zip: | Office Street Address: | | | | | Phone: | | | City: | State: | | Zip: | | Medication Information (required) | | | | | | | | Medication Name/Dosage Form/Strength: | | | | | | | | 􀂉 Check if requesting brand | | | Directions for Use: | | | | | 􀂉 Check if request is for continuation of therapy | | | | | | | | Clinical Information (required) | | | | | | | | What is the patient’s diagnosis for the medication being requested? ICD-10 Code(s): | | | | | | | | What medication(s) has the patient tried and had an inadequate response to? (Please specify ALL medication(s)/strengths tried, length of trial, and reason for discontinuation of each medication) | | | | | | | | What medication(s) does the patient have a contraindication or intolerance to? (Please specify ALL medication(s) with the associated contraindication to or specific issues resulting in intolerance to each medication) | | | | | | | | Are there any supporting labs or test results? (Please specify) | | | | | | | | Quantity limit requests:
What is the quantity requested per DAY?
What is the reason for exceeding the plan limitations?
􀂉 Titration or loading-dose purposes
􀂉 Patient is on a dose-alternating schedule (e.g. , one tablet in the morning and two tablets at night, one to two tablets at bedtime)
􀂉 Requested strength/dose is not commercially available
􀂉 There is a medically necessary justification why the patient cannot use a higher commercially available strength to achieve the same dosage and remain within the same dosing frequency. Please specify:
􀂉 Patient requires a greater quantity for the treatment of a larger surface area [Topical applications only]
􀂉 Other:
Note: If the patient exceeds the maximum FDA approved dosing of 4 grams of acetaminophen per day because he/she needs extra medication due to reasons such as going on a vacation, replacement for a stolen medication, provider changed to another medication that has acetaminophen, or provider changed the dosing of the medication that resulted in acetaminophen exceeding 4 grams per day, please have the patient’s pharmacy contact the Optum Rx Pharmacy Helpdesk at (800) 788-7871 at the time they are filling the prescription for a one-time override. | | | | | | | DO NOT COPY FOR FUTURE USE FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED Prior Authorization Request Form (Page 2 of 2) DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED 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 coverage determination request is not for a buy and bill drug. Optum Rx is not authorized to review requests for medications Supplied by the physician's o

FAQs

What information is required from the member on this form?

The form requires member name, insurance ID, date of birth, street address, city/state/zip, and phone.

What medication details must be provided for the prior authorization request?

It requests medication name/dosage form/strength, directions for use, and whether the request is for brand use or continuation of therapy.

What clinical information is required to justify the request?

The form asks for the patient’s diagnosis and ICD-10 code(s), prior medications tried with reasons for discontinuation, contraindications or intolerance details, supporting labs or test results, and quantity limit request reasons when applicable.

Sep 17, 2026

Uploaded by Fans