CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization Request Form for Medications

A payer form and instructions for providers to request prior authorization for medications (including antidepressants) for Colorado Rocky Mountain Health Plans members; governs submission requirements and clinical information to support authorization decisions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Request Form for Medications

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the full Prior Authorization Request Form to 866-940-7328 and allow at least 24 hours for review; include member, provider, and medication clinical details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

866-940-7328fax number

800-310-6826phone

24 hoursminimum review allowance

Chart notes requiredsupporting documentation

3 preferred trialsantidepressant trial

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Coverage Criteria and Required Clinical Information

Information and trial criteria

Information requested to support coverage decisions includes:

Submission completeness: Completed form with member and provider information, medication name/strength/directions/quantity, ICD-10 code, pregnancy status, prescriber signature/specialty, and chart notes must be provided.

Supports evaluation of medical necessity.

Continuation therapy: If continuation of therapy is indicated, documentation of start date and documented positive clinical response is requested.

From continuation-specific fields.

Antidepressant step requirement: For antidepressants, documentation that the patient has tried and failed three preferred antidepressants from at least two different antidepressant subclasses is requested; include prior medication names, dates, and reasons for failure/discontinuation.3 failed preferred antidepressants

Applies to requests under the antidepressant section.

The form references the member's preferred drug list (PDL) and asks providers to explain why preferred medications would not meet the patient’s needs. Providers should consult the PDL at the payer website for available alternatives when completing the prior authorization request and document a clear clinical rationale if a non‑preferred agent is requested.

Requests must include required supporting documentation. Chart notes, a prescriber signature, the prescriber specialty, and the date must be submitted with the form. Requests submitted without these items may be considered incomplete and may not be medically reviewable.

Diagnosis and Billing Codes

Diagnosis CodesICD-10

ICD-10 CODE

Field to capture the applicable ICD-10 diagnosis code for the requested medication

Submission Instructions and Provider Requirements

Note

Form submission and processing

Prior Authorization Request Form: Complete the entire form and fax to 866-940-7328. If you have questions, call 800-310-6826. This form may contain multiple pages — complete all pages to avoid a delay. Allow at least 24 hours for review.

Fax: 866-940-7328
Phone: 800-310-6826
Allow at least 24 hours for review

Step Therapy

Antidepressant trial requirement

For certain antidepressant prior authorization requests, documentation must show the member has tried and failed three preferred antidepressants from at least two different antidepressant subclasses (examples: SSRI, SNRI, tricyclics, MAOI, NDRI, tetracyclics). List medications tried, dates, and reasons for failure.

Required documentation: names of 3 preferred antidepressants tried and failed
Must be from at least two antidepressant subclasses (e.g., SSRI, SNRI, tricyclics, MAOI, NDRI, tetracyclics)
Provide dates of therapy and reason for failure/discontinuation

Policy Background and Purpose

This Prior Authorization Request Form is used to request coverage for medications, including antidepressants. It captures clinical and drug‑specific information to support medical necessity determinations, including whether the request is for continuation of therapy and details of prior medication trials (medication name, strength, directions, dates of therapy, and reason for discontinuation). For antidepressant requests the form specifically collects trial history and asks providers to explain why preferred alternatives on the PDL would not meet the patient’s needs. The form also requires submission of supporting documentation such as chart notes and the prescriber’s signature and specialty to ensure the request is complete.

Definitions and Special Review Requirements

Continuation of therapy — definition/key value

DefinitionContinuation of therapy: patient is already receiving the medication and the form asks whether this is a continuation of therapy and whether there is documented positive clinical response.

Required evidenceIf continuation, indicate start date and whether there is documented positive clinical response (Yes/No).

PurposeCollected to support evaluation of ongoing medical necessity and continued coverage of the requested medication.

Form locationAppears in the Clinical and Drug Specific Information section under 'Is this a continuation of therapy?'.

SON second opinion — requirement for second opinion review by designated mental health specialist for certain ages

Definition

Initial Therapy Documentation Requirements

Initial therapy documentation

Initial therapy requests must include the following medication and prior-treatment details:

Medication details: Provide medication name, strength, directions for use, quantity requested, and ICD-10 diagnosis code (please be specific).

Captured on Section C - Medical Information.

Pregnancy status: Indicate whether the member is pregnant and provide due date if applicable.

Captured on Section C - Medical Information.

Prior medication history: List previous medication trials with strength, directions, dates of therapy, and reason for failure or discontinuation.

Use Section D - Previous Medication Trials to document prior therapy.

Continuation of Therapy Requirements

Continuation therapy requirements

For continuation requests, provide evidence of ongoing clinical benefit:

Continuation evidence: Indicate that the request is for continuation of therapy and provide the therapy start date.

Section A asks whether this is a continuation and requests start date if yes.

Clinical response: Document whether the patient has a documented positive clinical response to the medication.

Captured in Clinical and Drug Specific Information (question about documented positive clinical response).

SON second opinion (pediatric): For patients 17 years of age or younger, indicate whether a Second Opinion Network (SON) review by an agency-designated mental health specialist has been performed when required.

SON second opinion requirement applies to pediatric patients per the form.

Step Therapy and Prior Trial Table

Medication Name	Dates of Therapy	Reason for Discontinuation

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Request Form for Medications

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the full Prior Authorization Request Form to 866-940-7328 and allow at least 24 hours for review; include member, provider, and medication clinical details.

SourceLink

On This Page

Documentation Required

Required documentation

Chart notes supporting the medical necessity of the request are required. The request must include prescriber signature, prescriber specialty, date, member demographics, and specific diagnosis including ICD-10 code. For continuation requests, indicate start date and document positive clinical response if applicable. For pediatric cases (≤17), include second-opinion review documentation when required.

Include chart notes documenting rationale and clinical course
Prescriber signature and prescriber specialty required
Include date of request and member demographics (name, member ID, DOB, contact)
Provide specific diagnosis with ICD-10 code
For continuation: list start date and document clinical response
For patients ≤17: include Second Opinion Network review documentation when required

Denial Risk

Incomplete documentation triggers denial

Incomplete or missing documentation may delay processing or result in denial of the request. Missing chart notes, absent prescriber signature or specialty, failure to document prior medication trials (including dates/reasons), or omission of required diagnosis/ICD-10 code are common reasons for denial. Ensure all fields and supporting records are included with the faxed form to avoid denial.

Missing chart notes or clinical documentation may lead to denial
Absent prescriber signature or specialty can cause denial or delay
Failure to document prior medication trials (names, dates, reasons) risks denial
Omit diagnosis or ICD-10 code — denial likely

SON second opinion: required second opinion review by an agency-designated mental health specialist from the Second Opinion Network (SON) for patients 17 years of age or younger.

ApplicabilityOnly required for patients 17 years of age or younger as indicated on the form question.

Form questionForm asks: 'For patients 17 years of age or younger: Has an agency-designated mental health specialist from the Second Opinion Network (SON) performed a required second opinion review? Yes No'.

Use in reviewResponse documents whether the required second opinion was obtained and supports authorization decisions for pediatric cases.

Formulary alternatives justification: Provide an explanation why preferred medications on the patient's PDL would not meet the patient's needs.

Section E requests justification and references the patient PDL for preferred alternatives.