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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
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Office use only: General_CMS_2019Oct-W
Prior Authorization Request Form (Page 2 of 2)
DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED
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 OptumRx Pharmacy Helpdesk at (800) 788-
7871 at the time they are filling the prescription for a one-time override.
Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to
this review?
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Please note: This request may be denied unless all required information is received.
If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555.
For urgent or expedited requests please call 1-800-711-4555.
This form may be used for non-urgent requests and faxed to 1-844-403-1028.