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Prior Authorization Request Form Fax Back To: 1-800-853-3844 Phone: 1-800-711-4555 5 AM 7 PM PT M-F or visit www.OptumRx.com and click Health Care Professionals for online real-time submission 24/7
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What is is this medication a?
This medication is used to treat high blood pressure.
Who is required to file is this medication a?
Healthcare providers are required to file this medication.
How to fill out is this medication a?
This medication should be filled out with the dose and frequency specified by the doctor.
What is the purpose of is this medication a?
The purpose of this medication is to regulate blood pressure.
What information must be reported on is this medication a?
Information such as patient name, dosage, and frequency must be reported on this medication.
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