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Optumrx Tier Exception Form

Optumrx Tier Exception Form

Use a optumrx tier exception form template to make your document workflow more streamlined.

ID#: NPI#: Date of Birth: Office Phone: Street Address: Office Fax: City: State: Zip: Specialty: Office Street Address: Phone: City: State: Zip: Medication Information (required) Medication Name: Strength: Is This Medication a New Start?  Yes  No Dosage Form: Directions for Use: Clinical Information (required) What is the patient’s diagnosis for the medication being requested? ICD-9/10 Code(s): _____________________________________ What medication(s) has the patient tried...
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