CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prescription Drug Prior Authorization and Step Therapy Exception Request Form

This document is a form and instructions for clinicians to request prior authorization or a step-therapy exception for prescription drugs for Colorado Rocky Mountain Health Plans members; it affects prescribers, clinic staff, and plan utilization reviewers processing PA/step-therapy exception requests.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrescription Drug Prior Authorization and Step Therapy Exception Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization or step therapy exception requests using the form or online via the payer's Prior Authorization and Notification Tool.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multi-pageform length

patient, prescriber, medicationsections included

onlinesubmission option

requiredprescriber attestation

Coverage and Submission Criteria

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Coverage and submission criteria

The form collects information the plan will use to determine coverage via prior authorization or to grant a step therapy exception.

Patient identifying information must be provided (patient name, member ID).

Insurance information must be provided; include primary/secondary payer and prior authorization number if known.

Prescriber attestation and signature or electronic ID verification required; include date.

Indicate whether request is for new therapy, renewal, or step therapy exception; if renewal, provide date therapy initiated and duration of therapy.

Provide medication details: medication name, dose/strength, frequency, route/administration, administration location, quantity, length of therapy/# refills, and whether paid under insurance or other.

List diagnoses and include applicable ICD-10 code(s).

Document prior therapies tried: for each, provide drug name and dosage, duration of therapy (dates), and response/reason for failure or allergy.

Provide required clinical information to support the request: symptoms, laboratory results with dates (when needed to establish diagnosis or evaluate response), justification for initial or ongoing therapy or dose increase, and any contraindications to the plan's preferred drug.

Attachments: Attach supporting documentation as needed (chart notes, lab data, other clinical records).

Plan will record date/time request received and date/time of decision; decision options include Approved or Denied with comments or requested information.

Diagnosis and Clinical Documentation

Diagnosis codingICD-10

ICD-10

Diagnosis code(s) required to be listed on form

Required clinical documentation

Symptoms and clinical findingsProvide relevant symptoms and clinical information to support the prior authorization or step-therapy exception request.

Laboratory results with datesInclude lab results with dates; labs are required when needed to establish diagnosis or evaluate response.

Therapy justificationProvide justification for initial or ongoing therapy or increased dose, including prior therapies tried and responses or reasons for failure/allergy.

Contraindications to preferred drugDocument any contraindications to the health plan/insurer preferred drug to support a step-therapy exception.

Supporting attachmentsAttach chart notes, lab data, and any additional documentation pertinent to the request; attachments checkbox is provided on the form.

Prescriber attestation and signaturePrescriber must attest that information is true and accurate and provide signature or electronic I.D. verification and date.

Submission, Workflow, and Urgency

Prior Authorization

How to submit a PA or Step‑Therapy Exception

Submit prior authorization (PA) or step-therapy exception requests using the health plan's Prescription Drug Prior Authorization or Step Therapy Exception Request Form. You may submit online via the Prior Authorization and Notification Tool at www.UHCprovider.com/paan, by fax to the plan/medical group fax number listed on the form (if available), or by phone using the number on the member's ID card. Complete all applicable sections legibly and attach supporting documentation (chart notes, labs, etc.).

Online: www.UHCprovider.com/paan
Phone: number on member's ID card
Fax: plan/medical group fax# (if available)

Step Therapy

Required clinical and decision workflow

Required clinical and decision workflow — provide prior therapies tried, diagnoses (ICD‑10), and clinical rationale to support the PA or step‑therapy exception. Indicate whether the patient has tried preferred alternatives; for each prior medication include drug name, dosage, duration (dates), and reason for failure or intolerance. Include relevant symptoms, lab results with dates, justification for initial or ongoing therapy or dose increases, and any contraindications to the plan’s preferred drug. Attach all supporting documentation.

Prior therapies: drug name, dosage, duration (dates), response/reason for failure/allergy
Diagnoses: list ICD‑10 codes
Clinical rationale: symptoms, lab results with dates, justification for therapy or dose change
Document contraindications to preferred drugs
Attach chart notes, lab data, and other supporting records

Documentation Required

Urgency and required supporting documentation

Urgency and supporting documentation — indicate whether the request is Non‑Urgent or Exigent (urgent) on the form. Attach all required supporting documents. The prescriber must sign or provide electronic ID verification and attest that the information is true and accurate. The plan may audit and request medical records to verify the submission.

Mark request status: Non‑Urgent or Exigent Circumstances
Attachments: chart notes, lab results (with dates), and any other documentation supporting urgent need
Prescriber attestation: signature or electronic I.D. verification and date
Plan may perform routine audit and request medical records

Key Definitions

Step Therapy Exception Request

DefinitionA Step Therapy Exception Request is an indication on the form to request coverage of a medication without completing the plan's step therapy requirements (form includes a specific 'Step Therapy Exception Request' option).

PurposeUsed when prescriber requests that the patient be allowed access to the requested medication despite not having tried required preferred therapies or when prior therapies failed or are contraindicated.

Required informationMust include medication details (name, dose, duration), diagnoses (ICD-10), prior therapies tried with dates and responses, and clinical justification.

Submission and attachmentsSubmit via the form, online Prior Authorization and Notification Tool, or by phone; attach supporting documentation such as chart notes or lab data.

Exigent Circumstances

DefinitionExigent Circumstances are situations marked on the request (or indicated in supporting clinical information) that require expedited review due to urgent patient need.

Marking urgencyRequests may be marked as Non-Urgent or Exigent Circumstances on the form to indicate urgency level.

Supporting documentationInclude attachments and clinical information pertinent to the exigent circumstance (chart notes, labs) to support expedited consideration.

Submission optionsExigent requests can be submitted using the online Prior Authorization and Notification Tool or initiated by phone using the number on the member's ID card.