______________________________________________________________________________________________________________ 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: InjectableInsulin_UHCE&I_2015Nov-W.doc

Injectable Insulin Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

Member Information (required) Provider Information (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?* Yes No Does the prescriber confirm that the medication has been effective in treating the member’s medical condition?*

Directions for Use:

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: Apidra vial Apidra Solostar Humalog Cartridge (Quantity limit [QL] only) Humalog vial (QL only) Humalog KwikPen (QL only) Humalog Mix 50/50 Kwikpen (QL only) Humalog Mix 50/50 vial (QL only) Humalog Mix 75/25 Kwikpen (QL only) Humalog Mix 75/25 vial (QL only) Humulin 70/30 KwikPen (QL only) Humulin 70/30 vial (QL only) Humulin 70/30 Pen (QL only) Humulin N KwikPen (QL only) Humulin N vial (QL only) Humulin N Pen (QL only) Humulin R vial (QL only) Lantus vial (QL only) Lantus Solostar (QL only) Levemir vial (QL only) Levemir FlexPen (QL only) Levemir FlexTouch (QL only) Novolin 70/30 vial Novolin N vial Novolin R vial Novolog vial Novolog Cartridge

Novolog FlexPen Novolog FlexTouch Novolog Mix 70/30 vial Novolog Mix 70/30 FlexPen ***Please note: A review of the vial will be conducted unless otherwise indicated above. ***

Select the diagnosis below: Diabetes Mellitus Other diagnosis: ______________________________

Medication history*: For Novolin R requests, please answer the following:

Has the member experienced therapeutic failure after receiving the following? If yes, please check the duration of trial of each medication (if applicable): Yes No Humulin R or any of its inactive ingredients Duration of trial: ≥ 3 months or 30 days

Please list the reason for therapeutic failure, contraindication, or intolerance to Humulin R or any of its inactive ingredients: _____________ _______________________________________________________________________________________________________________ For Novolin N requests, please answer the following:

Has the member experienced therapeutic failure after receiving the following? If yes, please check the duration of trial of each medication (if applicable): Yes No Humulin N or any of its inactive ingredients Duration of trial: ≥ 3 months or 30 days

Please list the reason for therapeutic failure, contraindication, or intolerance to Humulin N or any of its inactive ingredients: _____________ _______________________________________________________________________________________________________________ For Novolin 70/30 requests, please answer the following:

Has the member experienced therapeutic failure after receiving the following? If yes, please check the duration of trial of each medication (if applicable): Yes No Humulin or any of its inactive ingredients Duration of trial: ≥ 3 months or 30 days Yes No Humulin 70/30 or any of its inactive ingredients Duration of trial: ≥ 3 months or 30 days

Please list the reason for therapeutic failure, contraindication, or intolerance to Humulin, Humulin 70/30 or any of its inactive ingredients: _______________________________________________________________________________________________________________

Please note: All information below is required to process this request Mon-Fri: 5am to10pm Pacific / Sat: 6am to 3pm Pacific

For real time submission 24/7 visit www.OptumRx.com and click Health Care Professionals OptumRx • M/S CA 106-0286 • 3515 Harbor Blvd. • Costa Mesa, CA 92626

______________________________________________________________________________________________________________ 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: InjectableInsulin_UHCE&I_2015Nov-W.doc

Injectable Insulin Prior Authorization Request Form (Page 2 of 2) DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

For Apidra, Apidra Solostar or Novolog (Pens and vials) requests, please answer the following:

Has the member experienced therapeutic failure after receiving the following? If yes, please check the duration of trial of each medication (if applicable): Yes No Humalog or any of its inactive ingredients Duration of trial: ≥ 3 months or 30 days

Please list the reason for therapeutic failure, contraindication, or intolerance to Humalog or any of its inactive ingredients: ______________ _______________________________________________________________________________________________________________ For Novolog Mix 70/30 (Pens and vials) requests, please answer the following:

Has the member experienced therapeutic failure after receiving the following? If yes, please check the duration of trial of each medication (if applicable):

Yes No Humalog 75/25 or any of its inactive ingredients Duration of trial: ≥ 3 months or 30 days

Please list the reason for therapeutic failure, contraindication, or intolerance to Humalog 75/25 or any of its inactive ingredients :_________ _______________________________________________________________________________________________________________

Quantity limit requests:

What is the quantity requested per MONTH? ________ Yes No Is a higher quantity clinically necessary to control the member’s blood glucose levels? * May not apply to all plans

Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review?

________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Please note: This request may be denied unless all required information is received.

For urgent or expedited requests please call 1-800-711-4555. This form may be used for non-urgent requests and faxed to 1-800-527-0531.