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Includes sections for prior medication trials, ICD-10 diagnoses, required clinical information such as symptoms, lab results, contraindications, and exigent circumstances documentation. 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information is required to submit a prescription drug prior authorization or step therapy exception request?","Question",{"text":63,"@type":64},"The form collects patient demographics, insurance identifiers, prescriber/requestor details, medication and therapy information, prior medication trials, diagnoses (ICD-10), and required clinical information such as symptoms, lab results with dates, contraindications, and any exigent circumstances documentation.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Where does the prescriber indicate attestation and provide authorization to submit the request?",{"text":68,"@type":64},"The prescriber attests the information is true and accurate to the best of knowledge and provides a prescriber signature or electronic ID verification along with a date.",{"name":70,"@type":61,"acceptedAnswer":71},"How will the plan/insurer respond to the submitted request?",{"text":72,"@type":64},"The plan/insurer use section records the request received 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Exigent Circumstances   \nInstructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization or step-therapy exception ~~re~~quest.  \nInformation contained in this form is Protected Health Information under HIPAA.  \n\n| Patient Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name: |  |  | Last Name: |  |  |  |  | MI: |  |  | Phone Number: |  |  |  |  |\n| Address: |  |  |  |  | City: |  |  |  |  |  |  | State: |  |  | Zip Code: |\n| Date of Birth: |  Male\u003Cbr> Female |  |  | Circle unit of measure\u003Cbr>Height (in/cm):  Weight (lb/kg):  |  |  |  |  | Allergies: |  |  |  |  |  |  |\n| Patient’s Authorized Representative (if applicable): |  |  |  |  |  |  | Authorized Representative Phone Number: |  |  |  |  |  |  |  |  |\n| Insurance Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Primary Insurance Name: |  |  |  |  |  |  | Patient ID Number: |  |  |  |  |  |  |  |  |\n| Secondary Insurance Name: |  |  |  |  |  |  | Patient ID Number: |  |  |  |  |  |  |  |  |\n| Prescriber Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  |  | Last Name: |  |  |  |  |  | Specialty: |  |  |  |  |  |\n| Address: |  |  |  |  |  | City: |  |  |  |  |  | State: |  | Zip Code: |  |\n| Requestor (if different than prescriber): |  |  |  |  |  |  | Office Contact Person: |  |  |  |  |  |  |  |  |\n| NPI Number (individual) : |  |  |  |  |  |  | Phone Number: |  |  |  |  |  |  |  |  |\n| DEA Number (if required): |  |  |  |  |  |  | Fax Number (in HIPAA compliant area): |  |  |  |  |  |  |  |  |\n| Email Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication / Medical and Dispensing Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  New Therapy  Renewal  Step Therapy Exception Request\u003Cbr>If Renewal: Date Therapy Initiated: Duration of Therapy (specific dates): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| How did the patient receive the medication?\u003Cbr> Paid under Insurance Name:  Prior Auth Number (if known):   Other (explain): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Dose/Strength: |  | Frequency: |  |  |  |  | Length of Therapy/\\#Refills: |  |  |  |  |  | Quantity: |  |  |\n| Administration:\u003Cbr> Oral/SL  Topical  Injection  IV  Other: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Administration Location:\u003Cbr> Physician’s Office\u003Cbr> Ambulatory Infusion Center |  |  Patient’s Home  Long Term Care\u003Cbr> Home Care Agency  Other (explain) : \u003Cbr> Outpatient Hospital Care   |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\nPrescription Drug Prior Authorization or Step Therapy Exception Request Form  \nPatient Name: ID\\#:  \nInstructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization or step therapy exception request.  \n\n| 1. Has the patient tried any other medications for this condition?  YES (if yes, complete below)  NO |  |  |\n| --- | --- | --- |\n| Medication/Therapy (Specify Drug Name and Dosage) | Duration of Therapy (Specify Dates) | Response/Reason for Failure/Allergy |\n| \u003Cbr>2. List Diagnoses: ICD-10: |  |  |\n| \u003Cbr>3. Required clinical information-Please provide all relevant clinical information to support a prior authorization or step therapy exception request review.\u003Cbr>Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose","cbCaierfYTW0BXe3","https://ap.wps.com/l/cbCaierfYTW0BXe3","pdf",235819,"English","# Patient and Plan Information\n## Patient Information\n## Insurance Information\n# Prescriber and Medication Details\n## Prescriber Information\n## Medication / Therapy Information\n# Clinical Justification and Review\n## Prior Medication Trials\n## Diagnoses (ICD-10)\n## Required Clinical Information and Attachments\n## Attestation and Decision","[{\"question\":\"What information is required to submit a prescription drug prior authorization or step therapy exception request?\",\"answer\":\"The form collects patient demographics, insurance identifiers, prescriber/requestor details, medication and therapy information, prior medication trials, diagnoses (ICD-10), and required clinical information such as symptoms, lab results with dates, contraindications, and any exigent circumstances documentation.\"},{\"question\":\"Where does the prescriber indicate attestation and provide authorization to submit the request?\",\"answer\":\"The prescriber attests the information is true and accurate to the best of knowledge and provides a prescriber signature or electronic ID verification along with a date.\"},{\"question\":\"How will the plan/insurer respond to the submitted request?\",\"answer\":\"The plan/insurer use section records the request received date/time, decision date/time, and whether the request is approved or denied, including any comments or requested additional information.\"}]","Prescription Drug Prior Authorization or Step Therapy Exception Request Form - 11/18 | PDF"]