Formulary Exception / Prior Authorization Request Form
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Governs submission and processing of requests for formulary exceptions, prior authorizations, quantity limit overrides, and step therapy determinations for CommunityCare members; applies to members, prescribers, and authorized representatives seeking coverage for pharmacy drugs.
No material clinical or coverage changes in this revision.
Coverage Criteria
Submission and clinical justification criteria
Formulary exception or utilization management override will be considered when the prescriber provides the following evidence:
Failure to complete all pages or attach required clinical notes may prevent approval.
Document specific drugs tried/contraindications, adverse outcomes, and duration of therapy where applicable.
Information used to evaluate necessity and any quantity‑limit or step‑therapy override requests.
No explicit clinical exclusions are listed on the request form. The form directs requesters to indicate the reason for the request (for example, a medication not on the formulary, a prior authorization requirement, a step therapy determination, or a quantity‑limit override) and to attach supporting clinical documentation, but it does not enumerate specific diagnoses, conditions, or patient characteristics that would automatically exclude coverage consideration.
The form does not present a list of specific conditions deemed "not medically necessary." Instead, determinations are driven by the clinical information submitted with the request — including the reason for the request, supporting clinical notes, and attestations from the member or prescriber. Review and approval are based on the clinical justification provided (for example, contraindication to formulary agents, therapeutic failure, stability on a non‑formulary drug, or other medical rationale).
Provider Actions and Requirements
Prior Authorization / Formulary Exception Request
Prior authorization required for drugs on the formulary that have utilization management controls. Submit this completed form with supporting clinical documentation; all pages must be completed and the prescribing physician must also complete page 2 and attach necessary clinical notes. You may request a formulary exception by phone or by sending this form via mail or fax to CommunityCare Pharmacy Help Desk.
- Use this form to request a formulary exception for non‑formulary drugs or formulary drugs that require prior authorization, step therapy, or quantity‑limit overrides.
- All pages must be completed with accurate information; incomplete submissions or missing clinical notes may delay or prevent approval.
Step Therapy Information Required
List previous alternate formulary drug(s) tried or contraindicated, the adverse outcome for each (e.g., toxicity, allergy, therapeutic failure), and duration of therapy when applicable. If the patient is stable on a non‑formulary drug, describe the anticipated significant adverse clinical outcome if switched.
- Provide: 1) Drug(s) contraindicated or tried; 2) Adverse outcome for each; 3) If therapeutic failure, length of therapy on each drug.
- If claiming stability on current therapy, describe anticipated significant adverse clinical outcome if medication is changed.
Required Documentation
The prescribing physician must complete the prescriber section (including diagnosis, medication details, strength/route, frequency, start date, expected length of therapy, quantity, patient height/weight, and drug allergies) and attach supporting clinical notes documenting medical necessity. Failure to attach required clinical notes and complete the prescriber section may result in denial.
- Attach relevant clinical notes that justify the exception (labs, prior treatment records, notes of adverse reactions, documentation of contraindications).
- Physician must sign/complete page 2 as instructed on the form.
Incomplete Submission Risk
Failure to complete all pages or attach required clinical notes may prevent approval. Requests must be processed within twenty‑four (24) hours of receipt per Oklahoma statute when applicable — provide complete documentation to avoid delays.
- Incomplete submissions or missing documentation risk denial or delayed determination.
- Submit forms by fax to 918-879-4309 or mail to CommunityCare, HMO Attn: Pharmacy Help Desk, PO Box 3249, Tulsa, OK 74101-3249.
Background
This form is intended to support clinical decision‑making for exceptions when a member needs a medication that is not on the plan formulary or when a drug is subject to utilization management controls (prior authorization, step therapy, or quantity limits). It captures the reason for the request and requires the prescribing provider to complete the prescriber section and attach necessary clinical notes so reviewers can evaluate contraindications, prior therapy trials, adverse outcomes, stability on current therapy, and other clinical justification for an exception.
Definitions
Step Therapy Details
| Prior formulary agent (name) | Was agent contraindicated? (Y/N) | Adverse outcome or reason for failure | Duration of therapy (start — stop or total duration) |
|---|---|---|---|
| (List specific prior formulary agent tried) | |||
| (Indicate if contraindicated — Y or N) | |||
| (Describe adverse outcome, intolerance, or therapeutic failure) | |||
| (Provide start and stop dates or total duration of therapy) |
Quantity Limits
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