[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288871-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-288871-en":126},{"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":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","coverage-exception-choice-prescriber-fax-form-pa-request","Coverage Exception - Choice Prescriber Fax Form - PA Request","","Coverage Exception Choice Prescriber Fax Form for submitting prior authorization (PA) requests for prospective, concurrent, and retrospective reviews. The form instructs prescribers to fax completed information to 800-424-3260 and includes sections for priority level, date of service, patient and prescriber details, and drug information. It also captures clinical criteria such as current treatment, prior use within 90 days, formulary alternatives tried, medical necessity, combination therapy, previous medication trials, and additional supporting documentation.",{"@graph":14,"@context":72},[15,34,55],{"@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/coverage-exception-choice-prescriber-fax-form-pa-request/288871/",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/coverage-exception-choice-prescriber-fax-form-pa-request/288871.png","ImageObject",442,249,{"name":42,"@type":43},"Patrick","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-07","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":30},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"Who is allowed to complete and submit the Coverage Exception Choice Prescriber Fax Form?","Question",{"text":62,"@type":63},"Only the prescriber may complete this form. The submission supports prospective, concurrent, and retrospective review requests.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"Where should the completed form be faxed and how are faster determinations handled?",{"text":67,"@type":63},"Fax the form to 800-424-3260. For faster coverage determinations, electronic PA requests can be submitted through CoverMyMeds.",{"name":69,"@type":60,"acceptedAnswer":70},"What key clinical sections are required for preauthorization consideration?",{"text":71,"@type":63},"The form requires priority level and dates when applicable, patient and prescriber information, drug details, and answers to criteria questions including prior treatments, formulary alternatives tried, medical necessity, and supporting documentation.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},288871,1791050843,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":135,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"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":30},549758146520,"https://ap-avatar.wpscdn.com/avatar/80002397d8c0411e94?_k=1775819394049821470","Coverage Exception  \nChoice Prescriber Fax Form  \nFax 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 [web.primetherapeutics.com/provider/forms](web.primetherapeutics.com/provider/forms) [or](or primetherapeutics.com/commercial-formularies)[ ](or primetherapeutics.com/commercial-formularies)[primetherapeutics.com/commercial-formularies](or 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:   Sex:  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:   Number 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):    \n2. 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. Has the patient tried and had an inadequate response to at least two formulary alternatives (any formulary tier), if available, for the diagnosis being treated with the requested agent?  \n Yes  No  \nIf Yes, please list:  \nIf No, are all available formulary (any formulary tier) alternatives are contraindicated, likely tobe less effective, or cause an adverse reaction or other harm for the patient?  \n Yes  No  \nIf Yes, please provide details:  \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) .  \n\n| 5. Please list any other medications that the patient will use in combination with the requested medication for treatment of this diagnosis.\u003Cbr>6. Is the requested agent medically necessary? |  |  |\n| --- | --- | --- |\n| | Yes  | No |\n| If Yes, please explain: |  |  |\n| 7. Please list all medications that the patient has previously tried and had an inadequate response, intolerance or contraindication to for the treatment of this diagnosis. Please specify whether the patient has tried brand-name products, generic products, or over-the-counter products.\u003Cbr>Medication:   Outcome of trial:   Date (from):   Date (to):   |  |  |\n| Medication:   Outcome of trial:  \u003Cbr>Date (from):   Date (to):   |  |  |\n| Medication:   Outcome of trial:  \u003Cbr>Date (from):   ","cbCaivTMW7H2chzz","https://ap.wps.com/l/cbCaivTMW7H2chzz","pdf",1149363,8,"English","# Priority Level\n# Patient Information\n# Prescriber Information\n# Drug Information\n# Criteria for All Requests\n## Criteria for Brand Name Products\n## Criteria for Aspirin Therapy\n## Criteria for Bowel Prep Therapy\n## Criteria for Breast Cancer Primary Prevention Therapy","[{\"question\":\"Who is allowed to complete and submit the Coverage Exception Choice Prescriber Fax Form?\",\"answer\":\"Only the prescriber may complete this form. The submission supports prospective, concurrent, and retrospective review requests.\"},{\"question\":\"Where should the completed form be faxed and how are faster determinations handled?\",\"answer\":\"Fax the form to 800-424-3260. For faster coverage determinations, electronic PA requests can be submitted through CoverMyMeds.\"},{\"question\":\"What key clinical sections are required for preauthorization consideration?\",\"answer\":\"The form requires priority level and dates when applicable, patient and prescriber information, drug details, and answers to criteria questions including prior treatments, formulary alternatives tried, medical necessity, and supporting documentation.\"}]","Coverage Exception - Choice Prescriber Fax Form - PA Request | PDF",1789634129]