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Collects patient identifiers, diagnosis details including ICD codes, medication name and dosing, expected therapy length, and clinical rationale for expedited review. Includes sections to attest medical necessity, request documentation requirements, provide fax submission instructions, and answer condition- and drug-specific questions for therapeutic classes such as antifungals, antiemetic (5-HT3) agents, and Celebrex.",{"@graph":63,"@context":110},[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/formulary-exception-prior-authorization-request-form/288529/",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/formulary-exception-prior-authorization-request-form/288529.png","ImageObject",442,249,{"name":88,"@type":89},"Aran","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104],{"name":105,"@type":106,"acceptedAnswer":107},"What happens if the requested drug/class is not listed on the second page?","Question",{"text":108,"@type":109},"For any drug/class not listed on page 2, attach additional information, but the additional pages cannot exceed two pages.","Answer","https://schema.org",{"og:url":78,"og:type":112,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":114,"canonical":78},"index,follow",{"doc_id":116,"site_id":56},288529,1790050420,{"code":4,"msg":5,"data":119},{"doc_id":116,"user_id":120,"nickname":88,"user_avatar":121,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":122,"file_id":123,"file_url":124,"file_type":125,"file_size":126,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":127,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":61,"update_tm":131,"read_time":9},137455076865,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Formulary Exception/Prior Authorization Request Form  \n\n| Patient Information |  | Prescriber Information |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Patient Name: |  | Prescriber Name: |  |  |  |\n| Patient ID\\#: |  |  |  |  |  |\n| Address: |  | Address: |  |  |  |\n| City: | State: | City: |  |  | State: |\n| Home Phone: | ZIP: | Office Phone \\#: |  | Office Fax \\#: | ZIP: |\n| Gender: M or F | DOB: | Contact Person at Doctor's Office: |  |  |  |\n| Diagnosis and Medical Information |  |  |  |  |  |\n| Medication: | Strength: |  |  | Frequency: |  |\n| Expected Length of Therapy: | Qty: | Day Supply: | If this is a continuation of therapy, how long has\u003Cbr>the patient been on the medication? |  |  |\n| Diagnosis: |  | Diagnosis(ICD) Code(s): |  |  |  |\n| FORM CANNOT BE EVALUATED WITHOUT REQUIRED CLINICAL INFORMATION |  |  |  |  |  |\n\n􀂅 Expedited/Urgent Review Requested: By checking this box and signing below, I certify that applying the standard review timeframe may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function.  \nWhat condition isthe drug being prescribed for?    \nPlease list all medicationsthe patient hastried specific to the diagnosisand specify below:  \nTherapeutic failure, including length of therapy for each drug and trial year:   Drug(s) contraindicated:   Adverse event (e.g. , toxicity, allergy) for each drug:    \nIs the request for a patient with one or more chronic conditions(e.g. , psychiatric condition, diabetes) who isstable on the current drug(s) and who might be at high risk for a significant adverse event with a medication change? Specify anticipated significant adverse event:  \n__________________________________________________________________________________________________________________________  \nDoes the patient have a chronic condition confirmed by diagnostic testing? If so, please provide diagnostic test and date:    \nDoes the patient have a clinical condition for which other alternativesare not recommended based on published guidelinesor clinical literature? If so, please provide documentation:    \nDoes the patient require a specific dosage form (e.g., suspension, solution, injection)? If so, please provide dosage form:   Are additional riskfactors present (e.g. , gastrointestinal (GI) risk, cardiovascular risk, age)? If so, please provide riskfactors:  \nOther: Please provide additional relevant information:   REQUIRED CLINICAL INFORMATION: PLEASE PROVIDE ALL RELEVANT CLINICAL DOCUMENTATION TO SUPPORT USE OF THIS MEDICATION.  \nPLEASE COMPLETE CORRESPONDING SECTION ON PAGE 2 FOR THE SPECIFIC DRUGS/CLASSES LISTED.  \n**FOR ANY DRUG/CLASS NOT LISTED ON PAGE 2, PLEASE ATTACH ADDITIONAL INFORMATION, BUT CANNOT EXCEED TWO PAGES .**  \nPRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED, TO EVALUATE REQUESTS .  \nPLEASE FAX COMPLETED FORM TO 1-888-836-0730.  \n\n| I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and t hat documentation supporting this information is available for review if requested by CVS Caremark™ , the health plan sponsor, or, if applicable, a state or federal regulatory agency. I understand that any person who knowingly makes or causes to be made a false record or statement that is material to a claim ultimately paid by the United States government or any state government may be subject to civ il penalties and treble damages under both the federal and state False Claims Acts. See, e. g., 31 U .S.C. §§ 3729-3733.\u003Cbr>Date:\u003Cbr>Prescriber Signature:     |\n| --- |\n| Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution of these documents is strictly prohibited. If you have received this information in error, please not","cbCaijNERE8RYodL","https://ap.wps.com/l/cbCaijNERE8RYodL","pdf",182130,"English","# Patient Information\n## Prescriber Information\n# Diagnosis and Medical Information\n## Expedited/Urgent Review Requested\n## Required Clinical Information\n# Drug-Specific Sections","[{\"question\":\"What happens if the requested drug/class is not listed on the second page?\",\"answer\":\"For any drug/class not listed on page 2, attach additional information, but the additional pages cannot exceed two pages.\"}]","Formulary Exception - Prior Authorization Request Form | PDF",1789633594]