[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288927-105":53,"doc-detail-288927-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","step-therapy-exemption-request-form-ohio-department-of-medicaid","STEP THERAPY EXEMPTION REQUEST Form - OHIO DEPARTMENT OF MEDICAID","","Ohio Department of Medicaid Step Therapy Exemption Request form for pharmacy services provided by Gainwell Technologies. Captures request date, review type (standard or urgent), administration setting, and whether the medication is given by patient/caregiver, pharmacist, or other healthcare provider. Requires individual demographics and Medicaid ID, prescriber and pharmacy contact details, and full drug specifics (drug name, strength, quantity, route, frequency, duration, new or renewal). Exemption rationale must include Ohio Rev. Code compliance with ICD-10 diagnosis, supporting documentation by exemption type I–III, and attestation with signature, fax and phone submission to Gainwell PA Helpdesk.",{"@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/step-therapy-exemption-request-form-ohio-department-of-medicaid/288927/",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/step-therapy-exemption-request-form-ohio-department-of-medicaid/288927.png","ImageObject",442,249,{"name":88,"@type":89},"Caleb Sterling","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-09","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"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 Step Therapy Exemption Request?","Question",{"text":108,"@type":109},"The form requires request date, review type, administration/provider setting, individual demographics and Medicaid ID, prescriber and pharmacy contact details, and the requested drug’s specifics including strength, quantity, route, frequency, and duration.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What must be included in the exemption rationale to avoid delays?",{"text":113,"@type":109},"The diagnosis with ICD-10 code must be included, along with the rationale for exemption in accordance with Ohio Rev. Code § 5164.7514 and any additional supportive narrative.",{"name":115,"@type":106,"acceptedAnswer":116},"What documentation is required for exemption Types I, II, and III?",{"text":117,"@type":109},"Type I needs evidence the required drug is contraindicated (and supporting medical literature if not in the same PDL categories). Type II needs proof a previous non-step therapy medication was trialed and stopped due to lack of efficacy/effectiveness, diminished effect, or adverse event. Type III needs documentation the medication has been used for 6+ months and that the disease state is improved or stabilized.","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},288927,1791542857,{"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":135,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},962084925290,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","OHIO DEPARTMENT OF MEDICAID  \nSTEP THERAPY EXEMPTION REQUEST  \nPharmacy services provided by: Gainwell Technologies  \n|  |  |\n| --- | --- |\n| Request Date: | Review Type Requested ☐ Standard ☐ Urgent |\n\nThis medication will be administered by ☐ Patient/Caregiver ☐ Pharmacist ☐ Other Healthcare Provider  \nAt: ☐ Home ☐ Long-Term Care Setting (NF/ICF) ☐ Hospice ☐ Pharmacy ☐ Other  \n\n| Individual’s Full Name (Last, First) |  |  |  | Individual’s Date of Birth\u003Cbr>/ / |  |  | Individual’s Medicaid ID Number |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Sex | Height |  |  |  | Weight |  |  |  | Age |\n| Prescriber’s Full Name (Last, First) |  |  |  |  | Prescriber’s Address |  |  |  |  |\n| Prescriber’s NPI Number |  |  | Prescriber’s Phone Number\u003Cbr>( ) - |  |  | Prescriber’s Fax Number\u003Cbr>( ) - |  |  |  |\n| (If Known) Pharmacy’s Name |  |  |  | Pharmacy’s Phone Number\u003Cbr>( ) - |  |  | Pharmacy Fax Number\u003Cbr>( ) - |  |  |\n| Drug Requested |  | Strength |  |  | Quantity |  |  |  |  |\n| Route |  | Frequency |  |  | Duration of Therapy |  |  | ☐ New ☐ Renewal |  |\n\nDiagnosis and ICD-10 code (MUST BE INCLUDED TO AVOID DELAYS)  \nRATIONALE FOR EXEMPTION REQUEST  \nof for  \n\n| 1. Please indicate the rationale for Step Therapy Exemption in accordance with Ohio Rev. Code. § 5164.7514. |  |\n| --- | --- |\n| | Required prescription drug is contraindicated for the individual. (Type I)\u003Cbr>Required prescription drug was previously trialed while member was enrolled in other healthcare coverage. (Type II)\u003Cbr>The individual is stable on the prescribed drug for the medical condition. (Type III) |\n| 2. Please include the appropriate supporting documentation for your request based upon the nature exemption requested. Refer to the table below required documents. |  |\n\nFAILURE TO PROVIDE REQUESTED DOCUMENTATION WILL RESULT IN DENIED EXEMPTION REQUESTS  \n(Continued on Next Page)  \n(Rev. 05/07/2024) Page 1 of 3  \n\n| Type | Exemption Description | Necessary Documentation |\n| --- | --- | --- |\n| I | Required prescription drug is contraindicated for the individual. | • Documentation supporting required drug’s contraindication (i.e. , the drug’s package insert)\u003Cbr>• Documentation supporting member has identified contraindication.\u003Cbr>o If the contraindication is a disease state then diagnostic or other confirmatory test will need submitted.\u003Cbr>o If contraindication is due to specific organ dysfunction then lab results demonstrating dysfunction will need submitted (test must be performed within prior 6 months with exceptions for genetic conditions or pregnancy) .\u003Cbr>o If contraindication is due to concurrent therapy then must address why modifications to the other agent cannot be made including documented consultation with provider of other agent as appropriate.\u003Cbr>o If contraindication is due to an allergy, either direct or potentially associated, must provide complete history of previous allergic reaction inclusive of date of occurrence, type of reaction, and remedies taken.\u003Cbr>• Peer-reviewed medical literature supporting that the requested medication is medically necessary, safe, and effective for the individual’s diagnosis if not used for a labeled indication, consistent with Medical or Scientific Evidence definition in Ohio Rev. Code. § 3922.01.\u003Cbr>o Not required for drugs within the same Preferred Drug List (PDL) Categories. |\n| II | Required prescription drug was previously trialed while the individual was enrolled in other health care coverage. | • Documentation supporting that the previous non-step therapy medication was trialed while enrolled with other health care coverage.\u003Cbr>o Certification from the prescriber requesting step therapy exemption will satisfy this requirement.\u003Cbr>CONTINUED ON NEXT PAGE |\n\n\n| Type | Exemption Description | Necessary Documentation |\n| --- | --- | --- |\n|  |  | • Documentation supporting that the previous medication trial was discontinued due to lack of efficacy or effectiveness, diminished effect, ","cbCaiiYf35dT62F9","https://ap.wps.com/l/cbCaiiYf35dT62F9","pdf",570775,9,"English","# Request Details\n## Individual and Prescriber Information\n## Drug Information\n## Exemption Rationale and Supporting Documentation\n## Attestation and Submission","[{\"question\":\"What information is required to submit a Step Therapy Exemption Request?\",\"answer\":\"The form requires request date, review type, administration/provider setting, individual demographics and Medicaid ID, prescriber and pharmacy contact details, and the requested drug’s specifics including strength, quantity, route, frequency, and duration.\"},{\"question\":\"What must be included in the exemption rationale to avoid delays?\",\"answer\":\"The diagnosis with ICD-10 code must be included, along with the rationale for exemption in accordance with Ohio Rev. Code § 5164.7514 and any additional supportive narrative.\"},{\"question\":\"What documentation is required for exemption Types I, II, and III?\",\"answer\":\"Type I needs evidence the required drug is contraindicated (and supporting medical literature if not in the same PDL categories). Type II needs proof a previous non-step therapy medication was trialed and stopped due to lack of efficacy/effectiveness, diminished effect, or adverse event. Type III needs documentation the medication has been used for 6+ months and that the disease state is improved or stabilized.\"}]","STEP THERAPY EXEMPTION REQUEST Form - OHIO DEPARTMENT OF MEDICAID | PDF",1789634236]