CurrentCommunity-CarePolicy N/A

Formulary Exception / Prior Authorization Request Form

Describes the process and required information for requesting formulary exceptions, prior authorizations, quantity limit overrides, or step therapy determinations for CommunityCare members; applies to members, prescribers, and designated representatives seeking access to clinically appropriate drugs.

Policy Summary

PayerCommunity-Care

PolicyFormulary Exception / Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed form with clinical notes and prior therapy details to Navitus for prior authorization or formulary exception requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursrequired processing timeframe for determinations

Navitusphone

Faxaccepts requests by fax

Coverage criteria and required clinical information

Information required for evaluation

Requests will be considered when the requester provides clinical justification including previous treatments, contraindications, or risk of significant adverse outcome with medication change.

Required submission elements: Form must include member information, prescriber information, drug name/strength/route/frequency/quantity/duration, diagnosis, clinical notes, new prescription or date therapy initiated, patient height/weight, drug allergies, and signature; attach supporting documentation.

Supported by chunks 5 and 7

Previous treatment and outcomes: Provide a list of alternate formulary drug(s) that were tried or are contraindicated, with for each: adverse outcome (toxicity, allergy, therapeutic failure) and, if therapeutic failure, the length of therapy on each agent.

Supported by chunk 8

Clinical justification for exception

Policy Summary

PayerCommunity-Care

PolicyFormulary Exception / Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed form with clinical notes and prior therapy details to Navitus for prior authorization or formulary exception requests.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider responsibilities, documentation, and request requirements

Prior Authorization

Prior Authorization / Formulary Exception Required

Prior authorization or a formulary exception is required for any request involving drugs that are not on Community-Care's formulary or for drugs on the formulary that are subject to utilization management (prior authorization, quantity limit, or step therapy). Complete all pages of the request form and attach required clinical notes; requests may also be made by phone.

Use this form for non‑formulary drugs or formulary drugs requiring PA, quantity limit override, or step therapy exception.
All pages must be completed with accurate information; prescriber must complete the clinical portion and attach supporting notes.
Requests may be submitted by mail, fax, or phone.

Step Therapy

Step Therapy Determinations

When submitting a step therapy exception request, the form must indicate that a step therapy determination is being requested and include prior medication trials and clinical justification showing why the required prior steps are not appropriate or have failed.

Check the box indicating a step therapy determination is requested.
List prior medications tried, duration of each trial, and the clinical reason each trial failed (e.g., therapeutic failure, adverse reaction, contraindication).
Include documentation of clinical rationale for bypassing step therapy and anticipated benefit of the requested agent.

Documentation Required

Required Documentation for Request

Requests must include full, specific documentation to allow timely review. Missing or incomplete information may delay processing or result in denial.

Member information, signature (or representative) and date.
Prescriber information and signature; completed prescriber portion of the form.
Drug name, strength, route, frequency, quantity, and expected length of therapy.
Diagnosis and supporting clinical information, relevant medical history, patient height/weight, and drug allergies.
Clinical notes demonstrating prior therapies, lab results or other objective data as applicable, and justification for the exception.
If requesting an override of a quantity limit or continuation of therapy, include date therapy was initiated and rationale.

Denial Risk

Denial Triggers Related to Alternate Formulary Drugs

Failure to try or document contraindications to clinically appropriate alternative formulary drugs may result in denial of the request.

Document that alternate formulary drug(s) were tried and failed, were contraindicated, or caused adverse outcomes (specify drug(s), adverse outcome, and duration of trial).
If patient is stable on a non‑formulary drug, provide clinical justification describing the high risk of significant adverse clinical outcome if medication is changed.
Specify anticipated significant adverse clinical outcome if changing therapy.

Key definitions

Formulary exception — definition and scope

DefinitionA formulary exception is a request for a drug not on CommunityCare's covered drug list or to override utilization management requirements (prior authorization, quantity limit, or step therapy).

Who may requestMember, the member's designee, or the member's prescribing physician (or other prescriber) may submit a formulary exception request.

When to useUse this form to request access to medications not on the plan formulary or to request override of PA, quantity limits, or step therapy for formulary drugs.

Required submission elementsAll pages must be completed with accurate member and prescriber information; the prescribing physician must complete page 2 and attach necessary clinical notes and supporting documentation (e.g., prior therapy details, reasons alternate agents are contraindicated).

How to submitSubmit the completed form and clinical notes to Navitus by fax or contact the Navitus Prior Authorization Department by phone (toll free) as provided on the form.

OpenPayer

Formulary Exception / Prior Authorization Request Form

Coverage criteria and required clinical information

Provider responsibilities, documentation, and request requirements

Key definitions

Background and purpose