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The form requests medication, dosing, administration route and location, therapy type (new, renewal, or step-therapy exception), and prior treatment history. It also gathers diagnoses and required clinical information, including symptoms and dated lab results when applicable. An attestation section confirms accuracy to the best of the requester’s knowledge and acknowledges possible audits by the health plan or designees.",{"@graph":63,"@context":122},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/california-prescription-drug-prior-authorization-or-step-therapy-exception-request-form-request-form/288454/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/california-prescription-drug-prior-authorization-or-step-therapy-exception-request-form-request-form/288454.png","ImageObject",442,249,{"name":88,"@type":89},"Tawan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-24","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114,118],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required about the patient and prescriber on this form?","Question",{"text":108,"@type":109},"The form collects patient demographics (including date of birth and allergies), plus prescriber and requestor contact details such as names, addresses, and phone numbers, along with prescriber identifiers like NPI and DEA (if required).","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the form ask for medication and therapy details?",{"text":113,"@type":109},"It requests medication name, dose/strength, frequency, duration of therapy or renewal dates, quantity, administration route (e.g., oral, topical, injection, IV), and administration location (e.g., physician’s office or patient’s home).",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical documentation should be attached to support prior authorization or a step-therapy exception?",{"text":117,"@type":109},"Submit applicable supporting documentation such as chart notes and lab data. Provide symptoms, diagnoses with ICD-10 coding, prior medications tried with outcomes, and any relevant justification or contraindications, including dated lab results when needed.",{"name":119,"@type":106,"acceptedAnswer":120},"Is there an attestation section, and what does it require?",{"text":121,"@type":109},"Yes. The requester attests that the information provided is true and accurate to the best of their knowledge and acknowledges that the health plan, insurer, medical group, or their designees may perform routine audits and request medical information.","https://schema.org",{"og:url":78,"og:type":124,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":126,"canonical":78},"index,follow",{"doc_id":128,"site_id":56},288454,1790205776,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":88,"user_avatar":133,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":139,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":144,"read_time":73},2336475104042,"https://ap-avatar.wpscdn.com/avatar/22000c4c32af1715be0?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786537525561427321","Submit your [request online at: ](request online at: www.Availity.com)[www.Availity.com](request online at: www.Availity.com)  \nNon-Specialty drug Prior Authorization Pharmacy Specialty drug Prior Authorization Medical Specialty drug Prior Authorization  \nFax: 1-877-269-9916  \nFax: 1-866-249-6155  \nFax: 1-888-267-3277  \nFor FASTEST service, call 1-855-240-0535, Monday-Friday, [8 a.m. to 6 p.m. Central Time](8 a.m. to 6 p.m. Central Time)  \n[Visit ](Visit www.aetna.com/health-care-professionals.html)[www.aetna.com/health-care-professionals.html](Visit www.aetna.com/health-care-professionals.html) to access our Pharmacy Clinical Policy Bulletins  \nCALIFORNIA PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM  \nPlan/Medical Group Name:   Plan/Medical Group Phone\\#: ( )   \nPlan/Medical Group Fax\\#: ( )   Non-Urgent  Exigent Circumstances   \n\n| Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization or step-therapy exception request. Information contained in this form is Protected Health Information under HIPAA. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Patient Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  | Last Name: |  |  |  |  | MI: |  |  | Phone Number: |  |  |  |  |\n| Address: |  |  |  |  | City: |  |  |  |  |  |  | State: |  |  | Zip Code: |\n| Date of Birth: |  Male\u003Cbr> Female |  |  | Circle unit of measure\u003Cbr>Height (in/cm):  Weight (lb/kg):  |  |  |  |  | Allergies: |  |  |  |  |  |  |\n| Patient’s Authorized Representative (if applicable): |  |  |  |  |  |  | Authorized Representative Phone Number: |  |  |  |  |  |  |  |  |\n| Insurance Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Primary Insurance Name: |  |  |  |  |  |  | Patient ID Number: |  |  |  |  |  |  |  |  |\n| Secondary Insurance Name: |  |  |  |  |  |  | Patient ID Number: |  |  |  |  |  |  |  |  |\n| Prescriber Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  |  | Last Name: |  |  |  |  |  | Specialty: |  |  |  |  |  |\n| Address: |  |  |  |  |  | City: |  |  |  |  |  | State: |  | Zip Code: |  |\n| Requestor (if different than prescriber): |  |  |  |  |  |  | Office Contact Person: |  |  |  |  |  |  |  |  |\n| NPI Number (individual): |  |  |  |  |  |  | Phone Number: |  |  |  |  |  |  |  |  |\n| DEA Number (if required): |  |  |  |  |  |  | Fax Number (in HIPAA compliant area): |  |  |  |  |  |  |  |  |\n| Email Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication / Medical and Dispensing Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  New Therapy  Renewal  Step Therapy Exception Request\u003Cbr>If Renewal: Date Therapy Initiated: Duration of Therapy (specific dates): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| How did the patient receive the medication?\u003Cbr> Paid under Insurance Name:   Prior Auth. Number (if known):    Other (explain): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Dose/Strength: |  | Frequency: |  |  |  |  | Length of Therapy/\\#Refills: |  |  |  |  |  | Quantity: |  |  |\n| Administration:\u003Cbr> Oral/SL  Topical  Injection  IV  Other: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Administration Location:\u003Cbr> Physician’s Office\u003Cbr> Ambulatory Infusion Center |  |  Patient’s Home  Long Term Care\u003Cbr> Home Care Agency  Other (explain): \u003Cbr> Outpatient Hospital Care   |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\nSubmit your [request online at: ](request online at: www.Availity.com)[www.Availity.com](request online at: www.Availity.com)  \nNon-Specialty drug Prior Authorization Pharmacy Specialty drug Prior Authorization Medical Specialty drug Prior Authorization  \nFax: 1-877-269-9916  \n","cbCaijtPNrcGmQsH","https://ap.wps.com/l/cbCaijtPNrcGmQsH","pdf",3337838,6,"English","# Patient Information\n# Insurance Information\n# Prescriber Information\n# Medication / Medical and Dispensing Information\n# Clinical Information and Diagnoses\n# Attestation","[{\"question\":\"What information is required about the patient and prescriber on this form?\",\"answer\":\"The form collects patient demographics (including date of birth and allergies), plus prescriber and requestor contact details such as names, addresses, and phone numbers, along with prescriber identifiers like NPI and DEA (if required).\"},{\"question\":\"How does the form ask for medication and therapy details?\",\"answer\":\"It requests medication name, dose/strength, frequency, duration of therapy or renewal dates, quantity, administration route (e.g., oral, topical, injection, IV), and administration location (e.g., physician’s office or patient’s home).\"},{\"question\":\"What clinical documentation should be attached to support prior authorization or a step-therapy exception?\",\"answer\":\"Submit applicable supporting documentation such as chart notes and lab data. Provide symptoms, diagnoses with ICD-10 coding, prior medications tried with outcomes, and any relevant justification or contraindications, including dated lab results when needed.\"},{\"question\":\"Is there an attestation section, and what does it require?\",\"answer\":\"Yes. The requester attests that the information provided is true and accurate to the best of their knowledge and acknowledges that the health plan, insurer, medical group, or their designees may perform routine audits and request medical information.\"}]","CALIFORNIA PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM - request form | PDF",1789633502]