[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288536-105":53,"doc-detail-288536-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","formulary-exception-prior-authorization-request-form","Formulary Exception-Prior Authorization Request Form","","Formulary Exception/Prior Authorization Request Form collects patient demographics, prescriber details, and drug-specific information to support an insurance coverage request. It requires submission of relevant clinical documentation and includes questions for expedited review, continuation of therapy criteria, prior medication history with failure or contraindication reasons, and assessment of ongoing medical necessity. The form also addresses special conditions, chronic diagnoses, dosage form needs, comorbid contraindications, and specific diabetic supply requests. It concludes with attestation, prescriber signature, fax instructions, and drug-class sections such as topical antifungals.",{"@graph":63,"@context":118},[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/288536/",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/288536.png","ImageObject",442,249,{"name":88,"@type":89},"Jasmine","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information does the formulary exception/prior authorization request form collect?","Question",{"text":108,"@type":109},"It collects patient information (name, ID, DOB, address, gender, contact details), prescriber information, and drug information such as medication/strength, directions, expected therapy length, quantity, day supply, diagnosis code, and route of administration.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What documentation is required to support the medication coverage request?",{"text":113,"@type":109},"The form instructs to provide all relevant clinical documentation; supplying only demographic and drug information may not be sufficient for coverage review.",{"name":115,"@type":106,"acceptedAnswer":116},"How does the form handle expedited or urgent review?",{"text":117,"@type":109},"By checking the expedited/urgent review box and signing, the requester certifies that the standard review timeframe may jeopardize the patient’s life or health or ability to regain maximum function.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288536,1789633605,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":9},2336478487870,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Formulary Exception/Prior Authorization Request Form  \n\n| Patient Information |  |  |  |  | Prescriber Information |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Patient Name: |  |  | DOB: |  | Prescriber Name: |  | NPI\\# |  |\n| Patient ID\\#: |  |  |  |  | Address: |  |  |  |\n| Address: |  |  |  |  | City: | State: |  | Zip: |\n| City: |  | State: | Zip: |  | Office Phone \\#: | Secure Office Fax \\#: |  |  |\n| Home Phone: |  |  | Gender: M or F |  | Contact Person at Doctor’s Office: |  |  |  |\n| Drug Information |  |  |  |  |  |  |  |  |\n| Medication and Strength: |  |  | Directions for use (Frequency): |  |  | Expected Length of Therapy: |  |  |\n| Qty: | Day Supply: |  |  | ICD10 Code/Diagnosis: |  | Route of Administration: |  |  |\n| PLEASE PROVIDE ALL RELEVANT CLINICAL DOCUMENTATION TO SUPPORT USE OF THIS MEDICATION. Solely providing demographic and drug information may not constitute a sufficient request for coverage.\u003Cbr>FOR THOROUGH REVIEW, ATTACH RELEVANT CLINICAL DOCUMENTATION. |  |  |  |  |  |  |  |  |\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.  \nContinuation of Therapy:  \n1. Has the patient been receiving the requested drug within the last 120 days? Yes or No  \n2. Has the requested drug been dispensed at a pharmacy and approved for coverage previously by a prior plan? Yes or No  \n3. How long has the patient been on the requested medication?   \n4. Has the patient had a positive response to treatment or had improvement in symptoms? Yes or No  \n5. Has the patient’s need for continued therapy been assessed within the previous year? Yes or No  \nIs the requested product being used for an FDA-approved indication or an indication supported in the compendia of current literature (examples: AHFS, Micromedex, current accepted guidelines)? Yes or No  \nDoes the prescribed dose/quantity fall within the FDA-approved labeling or dosing guidelines found in the compendia of current literature? Yes or No  \nPlease list ALL medications the patient has tried specific to the diagnosis and specify below:  \nMedication   Explanation for failure or contraindication    \nMedication   Explanation for failure or contraindication    \nMedication   Explanation for failure or contraindication    \n*ALL other medications tried and reasons for failure:    \nIs the request for a patient with a highly sensitive condition (e.g. , psychiatric condition, epilepsy, organ transplant) who is stable on the current drug(s) and who might be at high risk for a significant adverse event or harm with a medication change? If yes, specify anticipated significant adverse event:  \nDoes the patient have a chronic condition confirmed by diagnostic testing? If yes, please provide diagnostic test and date:   Does the patient require a specific dosage form (e.g. , suspension, solution, injection)? If yes, please provide dosage form and clinical explanation:  \nDoes the patient have a clinical condition for which other formulary alternatives are not recommended or are contraindicated due to comorbidities or drug interactions based on published clinical literature? If so, please provide documentation including medication names and clinical reasons.  \nIs the request for Diabetic Test Strips or Continuous Glucose Monitoring System (CGM)? If yes, please answer the relevant questions below.  \na. Test strips: Does the patient have an insulin pump? If yes, please provide make and model (e.g. , OmniPod, MiniMed 670G)  Does the patient have an insulin pump that is incompatible with Accu-Chek or OneTouch product? Yes or No  \nb. CGM: Is the patient using an intensive insulin regimen? Yes or No If for continuation of therapy, is the patient being assessed every 6 months for adherence to their CGM regimen and diabetes treatment plan? Yes or No Is the patient currently not mee","cbCaibXOxMKkTRzZ","https://ap.wps.com/l/cbCaibXOxMKkTRzZ","pdf",181904,"English","# Patient Information\n# Prescriber Information\n# Drug Information\n# Expedited/Urgent Review and Continuation of Therapy Questions\n# Medical Necessity Attestation and Signature\n# Confidentiality Notice\n# Specific Drug/Class Section: Topical Antifungals","[{\"question\":\"What information does the formulary exception/prior authorization request form collect?\",\"answer\":\"It collects patient information (name, ID, DOB, address, gender, contact details), prescriber information, and drug information such as medication/strength, directions, expected therapy length, quantity, day supply, diagnosis code, and route of administration.\"},{\"question\":\"What documentation is required to support the medication coverage request?\",\"answer\":\"The form instructs to provide all relevant clinical documentation; supplying only demographic and drug information may not be sufficient for coverage review.\"},{\"question\":\"How does the form handle expedited or urgent review?\",\"answer\":\"By checking the expedited/urgent review box and signing, the requester certifies that the standard review timeframe may jeopardize the patient’s life or health or ability to regain maximum function.\"}]","Formulary Exception-Prior Authorization Request Form | PDF"]