Capital RX, Inc. - Prior Authorization and Step Therapy Exception Request Form

Sep 17, 2026

Capital RX, Inc. prior authorization and step-therapy exception request form collects member, patient, and prescriber information needed for coverage review. It includes demographic details, insurance data, physician specialties, and requestor contact information, plus medication and dispensing fields such as new therapy, renewal dates, and step-therapy exception rationale. The form requires clinical justification, prior medication and outcomes, required lab results with dates when applicable, and confirmation/attestation of accuracy, along with confidential notice and fax instructions.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Member Information

Insurance Information

Prescriber Information

Request and Medication Details

Clinical Information and Attestation

Confidentiality Notice

/ŶƐƚƌƵĐƚŝŽŶƐ͗ 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 [CA ONLY]) . /ŶĨŽƌŵĂƚŝŽŶ ĐŽŶƚĂŝŶĞĚ ŝŶ ƚŚŝƐ ĨŽƌŵ ŝƐ WƌŽƚĞĐƚĞĚ ,ĞĂůƚŚ /ŶĨŽƌŵĂƚŝŽŶ ƵŶĚĞƌ ,/W􀀄􀀄 . NON-URGENT EXIGENT CIRCUMSTANCES Member Information LAST NAME: FIRST NAME: PHONE NUMBER: DATE OF BIRTH: | | | | | --- | --- | --- | ± | | | | | --- | --- | --- | ± ± | | | | | | --- | --- | --- | --- | | | | | --- | --- | | | | | --- | --- | ± | | | | | | --- | --- | --- | --- | STREET ADDRESS: | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | CITY: STATE: ZIP CODE: MALE FEMALE HEIGHT (in/cm) : WEIGHT (lb/kg) : ALLERGIES: If you are not the patient or the prescriber, you will need to submit a PHI Disclosure Authorization form with this request which can be found at the following link: ZZZ􀀑FDS􀀐U[􀀑FRP 3$7,(176¶ $87+25,=(' REPRESENTATIVE (IF APPLICABLE): AUTHORIZED REPRESENTATIVE PHONE NUMBER: | | | | | --- | --- | --- | ± | | | | | --- | --- | --- | ± | | | | | | --- | --- | --- | --- | Insurance Information PRIMARY INSURANCE NAME: PATIENT ID NUMBER: SECONDARY INSURANCE NAME: PATIENT ID NUMBER: Prescriber Information LAST NAME: FIRST NAME: PRESCRIBER SPECIALTY: E-MAIL ADDRESS: NPI NUMBER: DEA NUMBER: PHONE NUMBER: | | | | | --- | --- | --- | ± | | | | | --- | --- | --- | ± STREET ADDRESS: | | | | | | --- | --- | --- | --- | FAX NUMBER: | | | | | --- | --- | --- | ± | | | | | --- | --- | --- | ± | | | | | | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | CITY: STATE: ZIP CODE: REQUESTOR (if different than Prescriber) : OFFICE CONTACT PERSON: Continued on next page. © 2018, 􀀒ĂƉŝƚĂů Zǆ͕ >>􀀒 . All rights reserved. 􀀒ĂƉŝƚĂů Zǆ . Revision Date: 07/01/2018. WĂŐĞ ϭ ŽĨ Ϯ 0(0%(5¶6 LAST NAME: 0(0%(5¶6 ),567 1$0(􀀝 | Medication / Medical and Dispensing Information | | | | | --- | --- | --- | --- | | DĞĚŝĐĂƚŝŽŶ EĂŵĞ͗ | | | | | 􀀘ŽƐĞͬ^ƚƌĞŶŐƚŚ͗ | &ƌĞƋƵĞŶĐǇ͗ | >ĞŶŐƚŚ ŽĨ dŚĞƌĂƉǇͬηZĞĨŝůůƐ͗ | YƵĂŶƚŝƚǇ͗ | | New Therapy Renewal Step Therapy Exception Request (CA ONLY)
If Renewal: Date Therapy Initiated: Duration of Therapy (specific dates): | | | | | ,Žǁ ĚŝĚ ƚŚĞ ƉĂƚŝĞŶƚ ƌĞĐĞŝǀĞ ƚŚĞ ŵĞĚŝĐĂƚŝŽŶ͍
Paid under Insurance Name: Prior Auth Number (if known): Other (explain): | | | | | 􀀄ĚŵŝŶŝƐƚƌĂƚŝŽŶ͗
Oral/SL Topical Injection IV Other: | | | | | 􀀄ĚŵŝŶŝƐƚƌĂƚŝŽŶ >ŽĐĂƚŝŽŶ͗ WĂƚŝĞŶƚ͛Ɛ ,ŽŵĞ Long Term Care
WŚǇƐŝĐŝĂŶ͛Ɛ Office Home Care Agency Other (explain):
Ambulatory Infusion Center Outpatient Hospital Care | | | | | ϭ͘ ,ĂƐ ƚŚĞ ƉĂƚŝĞŶƚ ƚƌŝĞĚ ĂŶǇ ŽƚŚĞƌ ŵĞĚŝĐĂƚŝŽŶƐ ĨŽƌ ƚŚŝƐ ĐŽŶĚŝƚŝŽŶ͍ z􀀜^ ;ŝĨ ǇĞƐ͕ ĐŽŵƉůĞƚĞ ďĞůŽǁͿ EK | | | | --- | --- | --- | | DĞĚŝĐĂƚŝŽŶͬdŚĞƌĂƉǇ
(Specify Drug Name and Dosage) | 􀀘ƵƌĂƚŝŽŶ ŽĨ dŚĞƌĂƉǇ
(Specify Dates) | ZĞƐƉŽŶƐĞͬZĞĂƐŽŶ ĨŽƌ &ĂŝůƵƌĞͬ􀀄ůůĞƌŐǇ | | Ϯ͘ >ŝƐƚ 􀀘ŝĂŐŶŽƐĞƐ͗ | | /􀀒􀀘ͲϭϬ͗ | | | | | | ϯ͘ Z􀀜Yh/Z􀀜􀀘 􀀒>/E/􀀒􀀄> /E&KZD􀀄d/KE ʹ Please provide all relevant clinical information to support a prior authorization or step therapy exception request review (CA ONLY) . | | | | Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose and if patient has any contraindications for the health plan/insurer preferred drug. Lab results with dates must be provided if needed to establish diagnosis, or evaluate response. Please provide any addition

FAQs

What information is required from the member and patient?

The form requests last name, first name, phone number, date of birth, street address, city/state/ZIP, sex, height, weight, and allergies. If the requester is not the patient or prescriber, a PHI disclosure authorization form is also needed.

What medication details must be completed for a request?

It collects medication/dispensing information including whether the request is new therapy, renewal, or a step therapy exception. For renewal, it asks for the date therapy was initiated and duration of therapy, and for step therapy exceptions it requires explanation of the request context.

What clinical documentation is needed to support the prior authorization or step therapy exception?

It requests the diagnosis/therapy details, required prior medication history, responses, and reasons for failure or allergy where applicable. Lab results with dates must be provided when needed to establish diagnosis or evaluate response, and additional clinical information relevant to exigent circumstances and applicable legal requirements should be included.

Sep 17, 2026

Uploaded by Emma Wilson