Formulary Exception / Prior Authorization Request Form
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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.
No material clinical or coverage changes in this revision.
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.
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Clinical justification for exception
- Contraindication or adverse outcome: Alternate formulary drug(s) are contraindicated or previously tried with adverse outcome (e.g., toxicity, allergy). Specify drug(s) and adverse outcome for each.
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- Therapeutic failure: Alternate formulary drug(s) were tried and resulted in therapeutic failure. Specify drug(s) and length of therapy for each prior trial.
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- High risk with medication change: Patient is stable on current non-formulary drug(s) and there is a high risk of significant adverse clinical outcome with medication change. Describe the anticipated significant adverse clinical outcome.
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The form does not list any explicit clinical exclusions. It instead captures the request reason (for example: a non‑formulary drug, a previously covered drug, a medication covered by another insurer, or a formulary drug that requires prior authorization, step therapy, or quantity‑limit override) and asks for supporting clinical documentation to evaluate the exception or authorization request.
Coverage determinations are made from the clinical information submitted on the form and attached notes rather than from a preprinted list of 'not medically necessary' conditions. The form asks the prescriber to provide clinical justification and supporting documentation so the plan can assess whether an exception, prior authorization, step therapy determination, or quantity‑limit override is warranted.
Provider responsibilities, documentation, and request requirements
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 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.
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 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
Background and purpose
This form is used to request access to medications that are either not on the plan’s formulary or are subject to utilization management. It collects member and prescriber information, identifies whether the request is for a formulary exception, prior authorization, step therapy determination, or quantity‑limit override, and requires attached clinical notes and supporting documentation to justify the request.
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