CurrentUnitedHealthcarePolicy N/A

Optum Rx / UnitedHealthcare Prior Authorization Request Form

Administrative prior authorization form and instructions for pharmacy benefit requests administered by Optum Rx on behalf of UnitedHealthcare; governs how providers submit prior authorization requests and required documentation for pharmacy-managed medications.

Policy Summary

PayerUnitedHealthcare

PolicyOptum Rx / UnitedHealthcare Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form with required clinical documentation and prescriber attestation for Optum Rx review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

180lookback days

Mon-Fri 5am-10pm PTCoverMyMeds/Optum Rx hours

1-800-711-4555urgent phone

2022Mardoc id

Coverage Determination & Applicability

Form completion criteria

Coverage determination is made after review of the completed form and supporting documentation; the form collects the following items

Required form elements: Provider information, medication information (name/dose/brand indicator/directions), clinical information including diagnosis and ICD-10, prior medication trials with dates and durations, continuation therapy questions, and prescriber attestation must all be provided.

Missing information may lead to denial.

Coverage requirements described on this form may not apply to all plans. Providers must confirm member-specific benefit rules before assuming the form’s questions and documentation will satisfy coverage for a given UnitedHealthcare plan.

Diagnosis Codes & Lookback

Requested diagnosis codesICD-10

ICD-10 Code(s):

Field requesting ICD-10 diagnosis code(s) for the medication request

Prior use lookback

Policy Summary

PayerUnitedHealthcare

PolicyOptum Rx / UnitedHealthcare Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form with required clinical documentation and prescriber attestation for Optum Rx review.

SourceLink

On This Page

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Lookback periodHas the member been on the requested medication in the last 180 days

Current stabilizationIs the member currently stabilized on the requested medication (asked on form)

Safety/effectivenessHas the requested medication been safe and effective in treating the member's medical condition?

Required Provider Actions & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain prescription benefit requests administered by Optum Rx. Providers must complete the medication-specific form and fax it to the number on the form. Coverage determinations will be made based on the member's benefit plan rules.

Complete and fax the medication-specific prior authorization form to the listed Optum Rx fax number.
Coverage is determined based on the member's benefit plan rules.

Step Therapy

Step Therapy / Prior Trials

Form asks whether the member has tried another prescription drug in the same pharmacologic class or mechanism of action and requests listing of trials/failures. Providers must document prior trials, dates, and duration for each medication trial.

List medications tried, date of trial, and duration of trial for each prior therapy.
Indicate whether medications were discontinued for lack of efficacy, diminished effect, or adverse events.

Documentation Required

Required Documentation and Attestation

Chart documentation and medical records must be submitted with the completed fax form. The prescriber must attest that the information provided is true and accurate and understand UnitedHealthcare may audit and request records to verify accuracy.

Attach relevant chart documentation and medical records when faxing the form.
Prescriber must sign and date the attestation on the form.

Denial Risk

Information Completeness Required

This request may be denied unless all required information is received within established timelines. For urgent or expedited requests call 1-800-711-4555. Ensure all required fields on the form are completed before submission.

Incomplete requests may be denied; supply all requested information and supporting records.
Use the urgent/expedited phone number for time-sensitive reviews.

Program Background

Optum Rx administers certain pharmacy benefit services for UnitedHealthcare and requires that prescribers complete the medication and clinical information on this form when requesting coverage. The form collects clinical details and chart documentation to support a coverage determination, and the prescriber must attest that the information provided is true and accurate. UnitedHealthcare/Optum Rx may perform routine audits and request medical records to verify the submission; failure to provide required information within established timelines may result in denial. For urgent or expedited requests, contact 1-800-711-4555.

Definitions & Continuation

Continuation of therapy

Continuation request flagIs this request for continuation of therapy? (Yes/No)

Medical records submissionWill medical records be submitted documenting information supporting continuation? (Yes/No)

Effectiveness assessmentHas the requested medication been safe and effective in treating the member's medical condition? (Yes/No)

Prior trialsHas the member tried another prescription drug in the same pharmacological class or mechanism of action? (Yes/No) — document medications, dates, and durations on the form

Initial Therapy Requirements

Initial therapy / prior trials

Initial therapy information to document prior medication trials and reasons for discontinuation

Initial trial information: Provide prior medications tried with dates and duration, reasons for discontinuation (lack of efficacy, adverse event, diminished effect), and indicate if member had failure/contraindication/intolerance to listed medications.

Used to support initiation when step therapy is relevant.

Continuation of Therapy Criteria

Continuation of therapy

Questions used to determine eligibility for continued coverage

Continuation assessment: Is this request for continuation of therapy; will medical records be submitted; has the member been on the requested medication in the last 180 days or is currently stabilized; has the medication been safe and effective; list prior trials in same pharmacologic class or mechanism and reasons for discontinuation.180 days

Responses and supporting records required; chart documentation must be submitted with the form and prescriber attestation is required.

Documenting Prior Trials & Failures

Prior medication	Date of trial	Duration of trial	Reason for discontinuation (failure, intolerance, contraindication)
Medication:
Date of trial:
Duration of trial:
Provide reason (lack of efficacy, adverse event, intolerance, or contraindication)