[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288872-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-288872-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","choice-step-therapy-pa-form-fax-form","Choice Step Therapy PA Form - Fax Form","","The document provides a prescriber-only prior authorization/step therapy choice fax form used for prospective, concurrent, and retrospective medication reviews. It collects patient demographics and clinical diagnosis details, prescriber credentials, and comprehensive drug information including dosing, duration, quantity, and refills. The form requires answers to standard request criteria, including current use, prior 90-day treatment history, combination therapies, rationale versus alternatives, and prior failed medications, followed by a behavioral health criteria section and prescriber attestation.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/choice-step-therapy-pa-form-fax-form/288872/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/choice-step-therapy-pa-form-fax-form/288872.png","ImageObject",442,249,{"name":42,"@type":43},"Himbo","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-09","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who is allowed to complete this prior authorization/step therapy choice form?","Question",{"text":63,"@type":64},"Only the prescriber may complete the form. Incomplete forms will be returned for additional information.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"For what review types is the form intended?",{"text":68,"@type":64},"The form is for prospective, concurrent, and retrospective reviews.",{"name":70,"@type":61,"acceptedAnswer":71},"What documentation or information is required for preauthorization consideration?",{"text":72,"@type":64},"The form requests required documentation through the filled criteria sections, including diagnosis details (ICD), current and prior medication history, combination therapies, and rationale for the requested medication versus alternatives. Additional information should be attached as needed.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},288872,1791252368,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},687197100911,"https://ap-avatar.wpscdn.com/avatar/a000239b6f1da00475?x-image-process=image/resize,m_fixed,w_180,h_180&k=1785132997149421697","Prior Authorization/Step Therapy Choice Prescriber Fax Form Fax this form to 800-424-3260  \nPrime Therapeutics Management LLC partners with CoverMyMeds to allow for the submission of electronic PA requests. For faster coverage determinations, [go to](go to www.CoverMyMeds.com)[ ](go to www.CoverMyMeds.com)[www.CoverMyMeds.com](go to www.CoverMyMeds.com).  \nOnly the prescriber may complete this form. This form is for prospective, concurrent, and retrospective reviews. Incomplete forms will be returned for additional information. The following documentation is required for preauthorization consideration. For formulary information visit [primetherapeutics.com/commercial-formularies](primetherapeutics.com/commercial-formularies).  \nWhat is the priority level of this request?  Standard  \n Date of service (if applicable) :    \n Urgent ( Note: Urgent is defined as when the prescriber believes that waiting for a standard review could seriously harm the patient’s life, health, or ability to regain maximum function.)  \nToday’s Date:    \nPATIENT INFORMATION  \nPatient Last Name:   Patient First Name:   Patient ID:   Date of Birth:   Patient Phone:   Patient Street Address:   City:   State:   Zip:    \nSex:  Male  Female Height:    in.  cm Weight:    lbs.  kg  \nAllergies:    \nPRESCRIBER INFORMATION  \nPrescriber Last Name:   Prescriber First Name:   Specialty:   Email:   Prescriber NPI:   DEA:   Prescriber Phone:   Prescriber Fax:   Prescriber Street Address:   City:   State:   Zip:    \nDRUG INFORMATION  \nDrug Name:   Drug Form:   Drug Strength:   Dosing Frequency:   Length of Therapy:   Quantity:    \nNumber of Refills:   Day Supply:    New Therapy  Renewal If renewal, date therapy initiated:   If renewal, duration of therapy (specific dates):   to    \nCRITERIA FOR ALL REQUESTS  \nNote: Please attach any additional information that should be considered with this request.  \nPatient’s Diagnosis:  \nICD (Code):   ICD Description:    \n1. Is the patient currently treated with the requested medication?  \n Yes  No  \nIf Yes, how did the patient receive the medication?  \n Insurance (list name):    Samples  \n Other (please explain):   2. Has the patient been treated with the requested agent within the past 90 days?  \n Yes  No  \nIf Yes, is the patient at risk if therapy is changed?  \n Yes  No  \nIf Yes, explain:  \n3. Please list all other medications the patient will use in combination with the requested medication for the treatment of this diagnosis.  \n4. Please list all reasons for selecting the requested medication, strength, dosing schedule, and quantity over alternatives (e.g. , contraindications, allergies, history of adverse drug reactions to alternatives, lower dose has been tried, information supporting dose over FDA maximum) .  \n5. Please list all medications that the patient has previously tried and failed for treatment of this diagnosis. (Please specify whether the patient has tried brand-name products, generic products, or over-the-counter products.)  \nMedication:   Type:   Date (from):   Date (to):    \nMedication:   Type:   Date (from):   Date (to):    \nMedication:   Type:   Date (from):   Date (to):    \nCRITERIA FOR BEHAVIORAL HEALTH DIAGNOSES  \n\n| 6. Please list all reasons for selecting the requested medication over alternatives (e.g. , |  |\n| --- | --- |\n| contraindications, risk with change, started on while in hospital, allergies or history of adverse |  |\n| drug reactions, lower dose) . |  |\n|  | Attachments |\n| ATTESTATION |  |\n\nAttestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group, or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.  \nPrescriber’s Signature:   Date:    \n(By signature, the physician confirms the above information is accurate and verifiable by patient records.)  \nPlease fax or mail this form to:  \nPrime Therapeutics ","cbCairagqvgLVU18","https://ap.wps.com/l/cbCairagqvgLVU18","pdf",1043443,"English","# Patient Information\n# Prescriber Information\n# Drug Information\n# Criteria for All Requests\n# Criteria for Behavioral Health Diagnoses\n# Attestation","[{\"question\":\"Who is allowed to complete this prior authorization/step therapy choice form?\",\"answer\":\"Only the prescriber may complete the form. Incomplete forms will be returned for additional information.\"},{\"question\":\"For what review types is the form intended?\",\"answer\":\"The form is for prospective, concurrent, and retrospective reviews.\"},{\"question\":\"What documentation or information is required for preauthorization consideration?\",\"answer\":\"The form requests required documentation through the filled criteria sections, including diagnosis details (ICD), current and prior medication history, combination therapies, and rationale for the requested medication versus alternatives. Additional information should be attached as needed.\"}]","Choice Step Therapy PA Form - Fax Form | PDF",1789634130]