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The form prompts submission of supporting clinical documentation and includes sections for standard or expedited/urgent review with continuation-of-therapy questions. It collects prior treatment history, response to current therapy, diagnostic test evidence for chronic conditions, and device-specific details for diabetic test strips and continuous glucose monitoring. 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The form also asks for medication history and reasons for failure or contraindication.","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},283842,1791026617,{"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":8,"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":139,"read_time":9},962084928904,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","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 time  \nframe may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function. Continuation 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 Please 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 meet","cbCaiorafQOHdUha","https://ap.wps.com/l/cbCaiorafQOHdUha","pdf",242531,"English","# Patient Information\n# Drug Information\n# Clinical Documentation Requirement\n# Review Type (Expedited/Urgent)\n# Continuation of Therapy Questions\n# Prior Treatments and Clinical Rationale\n# Special Condition and Coverage Criteria\n# Diabetic Test Strips / CGM Questions\n# Prescriber Attestation and Signature\n# Confidentiality Notice","[{\"question\":\"What information must be provided to request prior authorization for a medication?\",\"answer\":\"The form requires patient demographics, prescriber details, medication name and strength, dosing directions and frequency, expected therapy length, diagnosis including ICD10 code, and route of administration.\"},{\"question\":\"When should the expedited/urgent review box be selected?\",\"answer\":\"Select expedited/urgent review when applying standard review timeframes could seriously jeopardize the patient’s life or health or the ability to regain maximum function.\"},{\"question\":\"What additional documentation is requested to support the coverage decision?\",\"answer\":\"Supporting clinical documentation is requested for thorough review; providing only demographic and drug information may be insufficient. The form also asks for medication history and reasons for failure or contraindication.\"}]","Global Prior Authorization Form - Prior Authorization Request | PDF",1789620785]