CurrentColorado Rocky Mountain Health PlansPolicy N/A

Washington Prior Authorization Request Form — Medical Necessity

Form used by providers and pharmacies in Washington to request prior authorization for medications, document clinical justification, and supply supporting clinical information to Colorado Rocky Mountain Health Plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyWashington Prior Authorization Request Form — Medical Necessity

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Washington Prior Authorization Request Form to 866-940-7328 and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24+ hrsminimum review time requested

866-940-7328fax number

800-310-6826phone

chart notes, labsrequired docs

Coverage Criteria

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Complete form fields: Patient and provider identifiers, medication name and strength, directions for use, quantity/days supply, prescriber signature, prescriber specialty, and date must be provided.

Form contains required fields to allow processing.

Supporting documentation: Chart notes, labs and all diagnostic tests confirming diagnosis are required with this request.

Failure to provide these may delay or cause denial.

Indication support: Requested drug must be prescribed in accordance with FDA labeling or for a condition supported in compendia (strength of evidence category A or B and strength of recommendation class 1 or 2a); if No, provider must explain.

Form asks provider to indicate Yes/No and explain if No.

Dosing and age limits: Drug should be prescribed within FDA age, dose and dosing frequency limits or supported in compendia; if No, provider must explain.

Form asks Yes/No and explanation.

Prior therapies/step therapy: Provider must document trials of first-line therapies recommended in North American or WHO evidence-based guidelines, FDA-approved or compendia-supported alternatives, including medication name, duration of trial and outcome; if not tried, explain why.

Other guidelines may be used case-by-case if submitted with the request.

inv-02: Continuation of therapy

For continuation requests, ALL of the following details are requested:

Continuation flag: Provider must indicate if this is a continuation of therapy (Yes/No) and provide the date the patient last received the drug.

Field present on form under continuation question.

Source of prior supply: Provider must state whether continuation is based on samples or manufacturer coupons (Yes/No).

Form includes checkbox for samples/coupons.

Clinical benefit: Provider must confirm whether clinical documentation demonstrates disease stability or a positive clinical benefit (Yes/No).

Response required to support continuing therapy.

The form itself does not list specific, standalone coverage criteria or exclusion conditions; coverage decisions are driven by completion of the required form fields and submission of supporting clinical documentation. Providers must complete patient and prescriber identifiers, medication details, directions, quantity/days supply, prescriber signature, specialty and date so the request can be processed.

Initial Therapy Requirements

inv-12: Initial therapy requirements

Initial therapy requests must document diagnosis, date of diagnosis, adherence to labeling/compendia, dosing limits, and prior therapies tried.

Diagnosis: Provide the patient’s diagnosis and the date of diagnosis for which the drug has been prescribed.

Field present on form.

Label/compendia support: Confirm if the drug is prescribed in accordance with FDA labeling or for a compendia-supported condition (classified as strength of evidence category A or B and strength of recommendation class 1 or 2a); if No, explain.

Form asks Yes/No and requires explanation when No.

Age/dose limits: Confirm the drug is within FDA age, dose and dosing frequency limits or supported in compendia; if No, explain.

Form asks Yes/No and requires explanation when No.

Prior therapy trials: Document trials of first-line therapies recommended in North American or WHO evidence-based practice guidelines, FDA-approved or compendia-supported therapeutic alternatives, including medication name, duration of trial and outcome; if not tried, explain why.

Form includes a table to list medications, durations and outcomes; other guidelines may be used case-by-case when submitted.

Continuation Criteria

inv-13: Continuation requirements

Information required when the request is for continuation of therapy.

Last dose date: Provide the date the patient last received this drug.

Field asked when continuation = Yes.

Samples/coupons: Indicate whether continuation is based on samples or manufacturer coupons (Yes/No).

Form contains checkboxes for this item.

Clinical stability: Provide clinical documentation demonstrating disease stability or positive clinical benefit.

Chart notes, labs and diagnostic tests confirming diagnosis are required with this request.

Step Therapy / Prior Treatment

Step	Requirement
1
Document trials of first-line therapies recommended in North American or World Health Organization (WHO) evidence‑based practice guidelines, FDA‑approved or compendia‑supported therapeutic alternatives. For each trial, list medication name, duration of trial, and outcome. If alternatives were not tried, provide an explanation (e.g., ineffective, contraindicated, or not tolerated).

Provider Actions & Submission Instructions

Prior Authorization

Submission and contact

Complete and fax the Washington Prior Authorization Request Form to 866-940-7328. Allow at least 24 hours for review. For questions call 800-310-6826.

Step Therapy

Prior treatment / step therapy documentation

Document whether the patient has tried first-line therapies recommended in evidence-based practice guidelines (e.g., North American or WHO), FDA-approved alternatives, or compendia-supported therapies. If tried, list each medication, duration of trial, and outcome. If not tried, explain why first-line therapies were not used.

Documentation Required

Required documentation

Chart notes, laboratory results, and all diagnostic tests confirming the diagnosis are required with this request. Include prescriber signature, prescriber specialty, prescriber NPI/ID, and date on the form.

Denial Risk

Missing supporting documentation

Failure to provide complete supporting documentation (chart notes, labs, diagnostic tests confirming diagnosis, or the completed sections about prior therapy and prescriber information) may delay review or result in denial of the request.

Background

This form is used to collect the clinical justification needed for medication prior authorization. It requires documentation of the patient’s diagnosis and date of diagnosis, confirmation that the requested drug is consistent with FDA labeling or compendia-supported indications (with explanation if not), age/dose/frequency conformity or justification for deviations, and documentation of prior therapies or reasons they were not tried. For continuation requests the form asks for the date the patient last received the drug, whether continuation is based on samples or manufacturer coupons, and whether clinical documentation demonstrates disease stability or a positive clinical benefit. Providers must include supporting chart notes, labs and diagnostic tests, and sign and date the form before faxing for review.

Definitions

Continuation of therapy — key details

Continuation flagProvider must indicate if this is a continuation of therapy and, if yes, provide the date the patient last received the drug.

Source of prior supplyProvider must state whether continuation is based on samples or manufacturer coupons (Yes/No).

Clinical benefit/stabilityProvider must confirm whether clinical documentation demonstrates disease stability or a positive clinical benefit (Yes/No).

Compendia support

Compendia evidence categoriesForm asks whether the condition is supported in compendia classified as strength of evidence category A or B.

Strength of recommendationForm asks whether the compendia support is class 1 or 2a recommendation.

Requirement for prescriber responseProvider must indicate Yes/No that prescribing is in accordance with FDA labeling or compendia (A/B; 1/2a) and explain if No.