[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-281599-105":53,"doc-detail-281599-en":127},{"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":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","medical-exceptionprior-authorizationprecertification-request-for-prescription-medications","Medical Exception/Prior Authorization/Precertification Request for Prescription Medications","","Medical Exception/Prior Authorization/Precertification Request for Prescription Medications is a structured prior authorization form used for requesting coverage decisions for both non-specialty and specialty prescription drugs. It collects patient demographics and insurance identifiers, prescriber and clinical details, diagnosis information with ICD codes, treatment history, and required supporting documentation. The form includes sections for urgent requests, physician attestations, medication and therapy parameters, chronic condition considerations, diagnostic testing, and drug-class specific prompts, along with confidentiality and submission instructions via fax or online.",{"@graph":63,"@context":119},[64,80,102],{"@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/medical-exceptionprior-authorizationprecertification-request-for-prescription-medications/281599/",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/medical-exceptionprior-authorizationprecertification-request-for-prescription-medications/281599.png","ImageObject",442,249,{"name":88,"@type":89},"Clementine","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-05","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"How are prior authorization requests submitted?","Question",{"text":109,"@type":110},"Requests can be faxed to the appropriate specialty or non-specialty fax number or submitted online via the provided online portal link. For fastest service, a dedicated phone number and service hours are listed.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information must be provided in the patient and prescriber sections?",{"text":114,"@type":110},"The form requires patient demographics and insurance ID, along with prescriber name, address, office telephone and fax details, diagnosis and medical information, and key patient identifiers such as date of birth and gender.",{"name":116,"@type":107,"acceptedAnswer":117},"What clinical documentation is required to support the request?",{"text":118,"@type":110},"The form instructs the requester to provide all relevant clinical documentation supporting medication use, including diagnostic test information and dates when applicable, pertinent lab values, and evidence addressing guideline-based alternatives or dosage form needs.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},281599,1790922322,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":73,"preview_page_count":4},1374391974564,"https://ap-avatar.wpscdn.com/avatar/14000253aa45c000a9e?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779874745381141002","Medical Exception/Prior Authorization/Precertification* Request for Prescription Medications  \nNon-Specialty drug Prior Authorization Requests Fax: 1-877-269-9916  \nSpecialty drug Prior Authorization Requests  \nFax: 1-888-267-3277  \nOR, Submit your request online at:  \n[www.availity.com](www.availity.com)[ ](www.availity.com)[Visit](Visit www.aetna.com/formulary to access)[ ](Visit www.aetna.com/formulary to access)[www.aetna.com/formulary](Visit www.aetna.com/formulary to access)[ to access](Visit www.aetna.com/formulary to access)[ ](Visit www.aetna.com/formulary to access)[our Pharmacy Clinical Policy Bulletins.](our Pharmacy Clinical Policy Bulletins.)  \nFor FASTEST service, call 1-855-240-0535, Monday-Friday, [8 a.m. to 6 p.m. Central Time](8 a.m. to 6 p.m. Central Time)  \n\n| Patient Information |  | Prescriber Information |  |  |\n| --- | --- | --- | --- | --- |\n| Patient Name |  | Today’s Date |  |  |\n| Patient Insurance ID Number |  | Physician Name |  |  |\n| Patient Address, City, State, ZIP |  | Physician Address |  |  |\n| Home Telephone |  | M. D. Office Telephone Number |  |  |\n| Gender | Patient Date of Birth | M. D. Office Fax Number |  |  |\n|  Male  Female |  |  |  |  |\n| Diagnosis and Medical Information |  |  |  |  |\n| Medication |  | Strength |  | Frequency |\n| Expected Length of Therapy | Quantity | Day Supply | If this is a continuation of therapy, how long has the patient been on the medication? |  |\n| Is this medication being used to treat a chronic or long-term condition for which this prescription medication may be necessary for the life of the patient? |  |  |  Yes  No |  |\n| PLEASE CHECK ALL BOXES THAT APPLY:\u003Cbr>Do you want a drug specific prior authorization criteria form faxed to your office?  Yes  No (If yes, no further questions are required) .\u003Cbr> What condition is the drug being prescribed for? ICD code   Diagnosis  \u003Cbr> Does the patient have a diagnosis of cancer?  Yes  No\u003Cbr> STEP THERAPY may be required. Please list all medications the patient has tried specific to the diagnosis and specify below:\u003Cbr>Therapeutic failure, including length of therapy for each drug:   Drugs (s) contraindicated:   Adverse even (e.g. , toxicity, allergy) for each drug:  \u003Cbr> Is the request for a patient with one or more chronic conditions (e.g. , psychiatric condition, diabetes) who is stable on the current drug(s) and who might be at high risk for a significant adverse event with a medication change? If so, specify anticipated significant adverse event:\u003Cbr>\u003Cbr> Has the condition been confirmed by diagnostic testing? If so, please provide diagnostic test and date:\u003Cbr>\u003Cbr> Please provide any pertinent lab testing values for the members diagnosis :  \u003Cbr>\u003Cbr> Does the patient have a clinical condition for which other alternatives are not recommended based on published guidelines or clinical literature? If so, please provide documentation:  \u003Cbr> Does the patient require a specific dosage form (e.g. , suspension, solution, injection)? If so, please provide dosage form:\u003Cbr>\u003Cbr> Are additional risk factors (e.g. , GI risk, cardiovascular risk, age) present? If so, please provide risk factors:  \u003Cbr>\u003Cbr> Other: Please provide additional relevant information:  \u003Cbr>\u003Cbr>REQUIRED CLINICAL INFORMATION: PLEASE PROVIDE ALL RELEVANT CLINICAL DOCUMENTATION TO SUPPORT USE OF THIS MEDICATION.\u003Cbr>PLEASE COMPLETE CORRESPONDING SECTION ON BACK PAGE FOR THE SPECIFIC DRUG/CLASS LISTED BELOW.\u003Cbr>Antiemetic (5-HT3) Agents/Erectile Dysfunction Agents/Stimulants/ Provigil, Nuvigil/Testosterones\u003Cbr>**FOR ANY DRUG/CLASS NOT LISTED ON THE BACK PAGE, PLEASE ATTACH ADDITIONAL INFORMATION, BUT CANNOT EXCEED TWO PAGES** PRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED, TO EVALUATE REQUESTS |  |  |  |  |\n\nGR-68988 (11-23) Page 1 of 6  \n\n|  Urgent Request: I certify that applying a standard review timeframe might seriously jeopardize the life or health of the patient. |  |\n| --- | --- |\n| I attest that the medica","cbCaigGBBiAJknBL","https://ap.wps.com/l/cbCaigGBBiAJknBL","pdf",1393545,6,"English","# Prior authorization submission instructions\n# Patient and prescriber information\n# Clinical information and diagnosis details\n# Medication and therapy details\n# Required clinical documentation\n# Urgent request attestation and confidentiality notice\n# Drug-class specific questions","[{\"question\":\"How are prior authorization requests submitted?\",\"answer\":\"Requests can be faxed to the appropriate specialty or non-specialty fax number or submitted online via the provided online portal link. For fastest service, a dedicated phone number and service hours are listed.\"},{\"question\":\"What information must be provided in the patient and prescriber sections?\",\"answer\":\"The form requires patient demographics and insurance ID, along with prescriber name, address, office telephone and fax details, diagnosis and medical information, and key patient identifiers such as date of birth and gender.\"},{\"question\":\"What clinical documentation is required to support the request?\",\"answer\":\"The form instructs the requester to provide all relevant clinical documentation supporting medication use, including diagnostic test information and dates when applicable, pertinent lab values, and evidence addressing guideline-based alternatives or dosage form needs.\"}]","Medical Exception/Prior Authorization/Precertification Request for Prescription Medications | PDF",1789566917]