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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. 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If the requester is not the patient or prescriber, a PHI disclosure authorization form is also needed.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What medication details must be completed for a request?",{"text":114,"@type":110},"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.",{"name":116,"@type":107,"acceptedAnswer":117},"What clinical documentation is needed to support the prior authorization or step therapy exception?",{"text":118,"@type":110},"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.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283899,1790639227,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},3848291630094,"https://eur-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","/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􀀄􀀄 .  \n NON-URGENT  EXIGENT CIRCUMSTANCES  \nMember Information  \nLAST NAME: FIRST NAME:  \nPHONE NUMBER: DATE OF BIRTH:  \n\n|  |  |  |\n| --- | --- | --- |\n\n±  \n\n|  |  |  |\n| --- | --- | --- |\n\n± ±  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n|  |  |\n| --- | --- |\n\n\n|  |  |\n| --- | --- |\n\n±  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\nSTREET ADDRESS:  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nCITY: STATE: ZIP CODE:  \nMALE  FEMALE HEIGHT (in/cm) :   WEIGHT (lb/kg) :   ALLERGIES:    \nIf 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  \n3$7,(176¶ $87+25,=(' REPRESENTATIVE (IF APPLICABLE):   AUTHORIZED REPRESENTATIVE PHONE NUMBER:  \n\n|  |  |  |\n| --- | --- | --- |\n\n±  \n\n|  |  |  |\n| --- | --- | --- |\n\n±  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\nInsurance Information  \nPRIMARY INSURANCE NAME: PATIENT ID NUMBER:  \nSECONDARY INSURANCE NAME: PATIENT ID NUMBER:  \nPrescriber Information  \nLAST NAME: FIRST NAME:  \nPRESCRIBER SPECIALTY: E-MAIL ADDRESS:  \nNPI NUMBER: DEA NUMBER:  \nPHONE NUMBER:  \n\n|  |  |  |\n| --- | --- | --- |\n\n±  \n\n|  |  |  |\n| --- | --- | --- |\n\n±  \nSTREET ADDRESS:  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\nFAX NUMBER:  \n\n|  |  |  |\n| --- | --- | --- |\n\n±  \n\n|  |  |  |\n| --- | --- | --- |\n\n±  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nCITY: STATE: ZIP CODE:  \nREQUESTOR (if different than Prescriber) : OFFICE CONTACT PERSON:  \nContinued on next page.  \n© 2018, 􀀒ĂƉŝƚĂů Zdž͕ >>􀀒 . All rights reserved.  \n􀀒ĂƉŝƚĂů Zdž . Revision Date: 07/01/2018.  \nWĂŐĞ ϭ ŽĨ Ϯ  \n0(0%(5¶6 LAST NAME: 0(0%(5¶6 ),567 1$0(􀀝  \n| Medication / Medical and Dispensing Information |  |  |  |\n| --- | --- | --- | --- |\n| DĞĚŝĐĂƚŝŽŶ EĂŵĞ͗ |  |  |  |\n| 􀀘ŽƐĞͬ^ƚƌĞŶŐƚŚ͗ | &ƌĞƋƵĞŶĐLJ͗ | >ĞŶŐƚŚ ŽĨ dŚĞƌĂƉLJͬηZĞĨŝůůƐ͗ | YƵĂŶƚŝƚLJ͗ |\n|  New Therapy  Renewal  Step Therapy Exception Request (CA ONLY)\u003Cbr>If Renewal: Date Therapy Initiated: Duration of Therapy (specific dates): |  |  |  |\n| ,Žǁ ĚŝĚ ƚŚĞ ƉĂƚŝĞŶƚ ƌĞĐĞŝǀĞ ƚŚĞ ŵĞĚŝĐĂƚŝŽŶ͍\u003Cbr> Paid under Insurance Name:   Prior Auth Number (if known):   Other (explain): |  |  |  |\n| 􀀄ĚŵŝŶŝƐƚƌĂƚŝŽŶ͗\u003Cbr> Oral/SL  Topical  Injection  IV  Other: |  |  |  |\n| 􀀄ĚŵŝŶŝƐƚƌĂƚŝŽŶ >ŽĐĂƚŝŽŶ͗  WĂƚŝĞŶƚ͛Ɛ ,ŽŵĞ  Long Term Care\u003Cbr> WŚLJƐŝĐŝĂŶ͛Ɛ Office  Home Care Agency  Other (explain): \u003Cbr> Ambulatory Infusion Center  Outpatient Hospital Care   |  |  |  |\n\n\n| ϭ͘ ,ĂƐ ƚŚĞ ƉĂƚŝĞŶƚ ƚƌŝĞĚ ĂŶLJ ŽƚŚĞƌ ŵĞĚŝĐĂƚŝŽŶƐ ĨŽƌ ƚŚŝƐ ĐŽŶĚŝƚŝŽŶ͍  z􀀜^ ;ŝĨ LJĞƐ͕ ĐŽŵƉůĞƚĞ ďĞůŽǁͿ  EK |  |  |\n| --- | --- | --- |\n| DĞĚŝĐĂƚŝŽŶͬdŚĞƌĂƉLJ\u003Cbr>(Specify Drug Name and Dosage) | 􀀘ƵƌĂƚŝŽŶ ŽĨ dŚĞƌĂƉLJ\u003Cbr>(Specify Dates) | ZĞƐƉŽŶƐĞͬZĞĂƐŽŶ ĨŽƌ &ĂŝůƵƌĞͬ􀀄ůůĞƌŐLJ |\n| Ϯ͘ >ŝƐƚ 􀀘ŝĂŐŶŽƐĞƐ͗ |  | /􀀒􀀘ͲϭϬ͗ |\n|  |  |  |\n| 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) . |  |  |\n| 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","cbCailkxi0UVoq20","https://ap.wps.com/l/cbCailkxi0UVoq20","pdf",434318,"English","# Member Information\n# Insurance Information\n# Prescriber Information\n# Request and Medication Details\n# Clinical Information and Attestation\n# Confidentiality Notice","[{\"question\":\"What information is required from the member and patient?\",\"answer\":\"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.\"},{\"question\":\"What medication details must be completed for a request?\",\"answer\":\"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.\"},{\"question\":\"What clinical documentation is needed to support the prior authorization or step therapy exception?\",\"answer\":\"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.\"}]","Capital RX, Inc. - Prior Authorization and Step Therapy Exception Request Form | PDF",1789621745]