[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288531-105":53,"doc-detail-288531-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","prescription-drug-prior-authorization-or-step-therapy-exception-request-form","Prescription Drug Prior Authorization or Step Therapy Exception Request Form","","Prescription drug prior authorization or step-therapy exception request form used to collect complete, legible information for review by a health plan or insurer. The form captures plan/medical group details, patient demographics and allergies, insurance identifiers, prescriber and requestor information, medication and administration specifics, therapy history including renewal dates and dosing, and prior medication trials. It also requests clinical information, diagnoses with ICD-10, supporting symptoms and lab data, attestation, and plan decision fields including approval or denial and comments.",{"@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/prescription-drug-prior-authorization-or-step-therapy-exception-request-form/288531/",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/prescription-drug-prior-authorization-or-step-therapy-exception-request-form/288531.png","ImageObject",442,249,{"name":88,"@type":89},"Mack Lee","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-22","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 is required to submit a prior authorization or step-therapy exception request?","Question",{"text":108,"@type":109},"Complete all applicable sections for patient, insurance, prescriber, and medication details, and attach relevant documentation such as chart notes or lab data. The form also requires clinical information supporting coverage or an exception request.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What does the form ask for under therapy history and step-therapy exception details?",{"text":113,"@type":109},"It requests whether this is a new therapy, renewal, or step-therapy exception request, including therapy initiation dates, duration, prior auth details (if known), dosing, frequency, quantity, and administration route and location.",{"name":115,"@type":106,"acceptedAnswer":116},"How are plan decisions recorded on the form?",{"text":117,"@type":109},"The plan/insurer section captures the date/time the request is received, the date/time of the decision, the decision outcome (approved or denied), and any comments or additional information requested.","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},288531,1790011616,{"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":139,"read_time":9},1236954509970,"https://us-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM  \nPlan/Medical Group Name:   Plan/Medical Group Phone\\#: (  )   \nPlan/Medical Group Fax\\#: ( ) Non-Urgent ■ Exigent Circumstances   \n| Instructions: 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. Information contained in this form is Protected Health Information under HIPAA. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Patient Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\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  \n\n| Patient Name: | ID\\#: |\n| --- | --- |\n\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\u003Cbr>(Specify Drug Name and Dosage) | Duration of Therapy\u003Cbr>(Specify Dates) | Response/Reason for Failure/Allergy |\n| 2. List Diagnoses: |  | ICD-10: |\n|  |  |  |\n| 3. Required clinical information-Please provide all relevant clinical information to support a prior authorization or step therapy exception request review. |  |  |\n| Please provide symptoms, lab results with dates and/or justification for ini","cbCaikGaQGPpyW8s","https://ap.wps.com/l/cbCaikGaQGPpyW8s","pdf",195443,"English","# Patient Information\n# Insurance Information\n# Prescriber Information\n# Medication / Medical and Dispensing Information\n# Medication Trials and Diagnoses\n# Required Clinical Information and Attachments\n# Attestation and Confidentiality Notice\n# Plan/Insurer Use Only","[{\"question\":\"What information is required to submit a prior authorization or step-therapy exception request?\",\"answer\":\"Complete all applicable sections for patient, insurance, prescriber, and medication details, and attach relevant documentation such as chart notes or lab data. The form also requires clinical information supporting coverage or an exception request.\"},{\"question\":\"What does the form ask for under therapy history and step-therapy exception details?\",\"answer\":\"It requests whether this is a new therapy, renewal, or step-therapy exception request, including therapy initiation dates, duration, prior auth details (if known), dosing, frequency, quantity, and administration route and location.\"},{\"question\":\"How are plan decisions recorded on the form?\",\"answer\":\"The plan/insurer section captures the date/time the request is received, the date/time of the decision, the decision outcome (approved or denied), and any comments or additional information requested.\"}]","Prescription Drug Prior Authorization or Step Therapy Exception Request Form | PDF",1789633597]