Proton Pump Inhibitors (Ppi) Prior Authorization Request Form

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Please note: All information below is required to process this request
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OptumRx • M/S CA 106-0286 • 3515 Harbor Blvd. • Costa Mesa, CA 92626
Proton Pump Inhibitors (PPI) Prior Authorization Request Form (Page 1 of 2)
DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED
Member Information
Provider Information
(required)
(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:
Strength:
Dosage Form:
 Check if requesting brand
 Yes  No Continuation of therapy? If “YES”, answer the following:
 Yes  No Has member been on this medication in the last 180 days?*
Directions for Use:
 Yes  No Does the prescriber confirm that the medication has been
effective in treating the member’s medical condition?*
Clinical Information
(required)
Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses OptumRx for certain pharmacy benefit services. Your patient’s
benefit plan requires that we review certain requests for coverage with the prescribing physician. This includes requests for benefit coverage beyond plan
specifications. Please complete the following questions and then fax this form to the toll free number listed below. Upon receipt of the completed form,
prescription benefit coverage will be determined based on the benefit plan’s rules.
Select the requested drug below:
 Aciphex (rabeprazole)
 Aciphex Sprinkle
 Dexilant
 Esomeprazole strontium
 Nexium capsule
 Nexium suspension
 Prevacid (lansoprazole)  Prevacid Solutab (lansoprazole ODT)
 Prilosec (omeprazole)
 Prilosec suspension
 Protonix (pantoprazole)
 Protonix Granules
 Zegerid (omeprazole-sodium bicarbonate)
 Zegerid suspension
Select the diagnosis below:
 Adjunct therapy to H. pylori eradication regimen
 Barrett’s Esophagus
 Erosive esophagitis
 Gastroesophageal reflux disease (GERD)
 H. pylori gastritis
 Hypersecretory conditions (such as Zollinger- Ellison Syndrome, endocrine adenomas, or systemic mastocytosis)
 Laryngopharyngeal reflux
 NSAID induced ulcer prevention
 Pancreatic enzyme mal-absorption
 Peptic/Gastric/Duodenal ulcer disease
 Other diagnosis: ______________________________
Please answer the following*:
 Yes  No Has the diagnosis been confirmed using appropriate diagnostic criteria?
 Yes  No Has the member failed treatment with an over-the-counter (OTC) medication [e.g., Nexium OTC, Prilosec OTC, Prevacid 24
Hour, Zegerid OTC] due to lack of effectiveness?
 Yes  No Is the member unable to tolerate an OTC medication (e.g., Nexium OTC, Prilosec OTC, Prevacid 24 Hour, Zegerid OTC)?
For brand Aciphex, Aciphex Sprinkle, Nexium capsule, Esomeprazole strontium, Prevacid (lansoprazole), brand Prilosec,
brand Protonix, and Zegerid (omeprazole/sodium bicarbonate) requests, also answer the following*:
Does the member have a history of failure, contraindication, or intolerance to the following?
 Yes  No Dexilant**
 Yes  No Pantoprazole tablet (generic Protonix)**
 Yes  No Omeprazole (generic Prilosec)**
 Yes  No Rabeprazole tablet (generic Aciphex)**
For Protonix granules and Prilosec suspension requests, also answer the following*:
Does the member have a history of failure, contraindication, or intolerance to the following?
 Yes  No Dexilant**
 Yes  No Pantoprazole (generic Protonix)**
 Yes  No Omeprazole (generic Prilosec)**
 Yes  No Rabeprazole (generic Aciphex)**
______________________________________________________________________________________________________________
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
PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information
in this document is against the law. If you are not the intended recipient, please notify the sender immediately.
Office use only: ProtonPumpInhibitors_UHCE&I_2016Jul-W.doc

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