Prior Authorization / Exception Submission Steps

Complete and submit a signed prior authorization or exception request using the full form. Include patient demographics (name, home address, city, state, zip, date of birth, contract number with prefix), request type (prior authorization, step therapy exception, quantity limit exception, appeal, mandatory generic exception, non‑formulary exception), and whether this is an initial authorization or renewal. Attach any additional medical information as needed.

• Patient-identifying information: Patient name, home address, city, state, zip, date of birth, contract number (include prefix).
• Request type: check appropriate box (Prior Authorization; Step Therapy Exception; Quantity Limit Exception; Appeal; Mandatory Generic Exception; Non‑Formulary Exception).
• Request timing: check Initial Authorization or Authorization Renewal; attach additional medical information when applicable.

Required Treatment and Medical History

Provide complete treatment and clinical documentation: list drug name, strength, frequency, quantity requested, duration of disease (years), place and route of administration, and whether a healthcare professional will administer. Include ICD‑10 codes, medical rationale (attach chart notes if possible), and a full treatment history showing medications tried, strengths/frequencies, dates of therapy, and outcomes. Indicate co‑morbid conditions that may affect therapy.

• Treatment details: Drug/Strength/Frequency/Quantity requested; Duration of disease; Place of service; Route of administration; Healthcare professional to administer (Yes/No).
• Clinical coding and rationale: ICD‑10 codes and medical rationale; attach chart notes when available.
• Treatment history: For each prior medication include drug, strength/frequency, dates of therapy, and outcome of therapy (list up to 5).
• Comorbidities: State whether any co‑morbid conditions affect therapy and list them if present.

Signature and Acceptable Documentation

The prescriber’s signature and date are required for processing. Attach any additional medical justification. Do not rely on manufacturer coupons or free samples as proof of prior therapy—these are not acceptable. This form is for prescription drug benefit authorization only and must be completely filled out.

• Prescriber Signature: Required for processing; include date.
• Acceptable attachments: chart notes, documentation of prior therapies (not manufacturer coupons or samples).
• Form completeness: the form must be completely filled out to be processed.

Submission Instructions

Submit the signed and completed form by fax or mail to Pharmacy Review.

• Fax: 1‑866‑606‑6021 (Fax the signed and completed form to Pharmacy Review).
• Mail: Pharmacy Review, Post Office Box 529, Auburn, AL 36831.