Formulary Exception / Prior Authorization Request Form
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This document governs requests for formulary exceptions, prior authorizations, step therapy overrides, and quantity limit exceedances for CommunityCare members; it applies to members, their designees, and prescribing providers seeking access to medications not routinely covered or subject to utilization management. It also outlines required information and processing timeframe.
No material clinical or coverage changes in this revision.
Coverage and Authorization Criteria
Formulary Exception / Authorization Criteria
Formulary exceptions, prior authorizations, step therapy overrides, and quantity limit exceptions are considered when the prescriber or member provides the required information and supporting clinical documentation. Covered when ALL of the following are met:
See chunks 0,5,7
See chunks 7,5,8
See chunks 5,8
See chunk 5
See chunk 8
See chunks 0,8
The form does not list any explicit exclusion conditions. There are no specific scenarios or drug categories described on the form as automatically excluded from consideration; requests are framed around the need for a formulary exception, prior authorization, step therapy determination, or quantity‑limit exceedance and evaluated based on the submitted clinical information.
The form does not define specific Not Medically Necessary conditions. Determinations about medical necessity are made based on the clinical documentation attached to the request and the plan’s coverage rules rather than by pre‑listed NMN criteria on the form.
Coding and Review Timeframes
| No codes listed |
Required Provider Actions and Documentation
Prior Authorization / Formulary Exception Required
Prior authorization or a formulary exception is required for drugs that are not on CommunityCare's formulary or for formulary drugs subject to utilization management (prior authorization, quantity limit, or step therapy). Submit the completed formulary exception/prior authorization form with all required supporting documentation. Contact the Pharmacy Help Desk for assistance: 918-594-5211, Toll Free 877-293-8628, TTY/TDD 800-722-0353, Fax 833-440-5194.
- Submit all pages of the form fully completed and accurate.
- Prescriber must complete, sign, and date page 2 and attach necessary clinical notes.
- Requests may also be made by phone to the Pharmacy Help Desk.
Required Clinical Documentation
The prescriber must provide and attach required clinical documentation to support the request. The clinical documentation must be complete, signed, and dated by the prescriber and should include diagnosis, relevant clinical notes, current and prior medications (including dates and durations), relevant laboratory results, drug allergies, patient height/weight, and the expected length of therapy.
- Attach supporting documents showing previous trials of formulary alternatives, including dates and outcomes.
- If step therapy is being overridden, document attempted agents, contraindications, adverse outcomes (e.g., toxicity, allergy, therapeutic failure), and duration of prior therapy.
- If patient is stable on a non-formulary drug, document risk of significant adverse clinical outcome if medication is changed and explain why alternatives are contraindicated or have failed.
Incomplete Requests May Be Denied
Incomplete or insufficient requests may be denied. Failure to provide all required information and attachments — including a completed prescriber-signed form and supporting clinical notes demonstrating medical necessity, prior therapy history, and any adverse outcomes — may result in denial. Requests are processed within statutory timeframes; urgent requests are subject to the expedited review provisions.
- Ensure all sections of the form are completed and that attachments clearly document medical necessity.
- For expedited requests, clearly indicate urgency and provide supporting clinical rationale.
Step Therapy Override Requirements
| Step | Requirement |
|---|---|
| 1 | Attach documentation of prior agent trials, including drugs tried or contraindicated; describe adverse outcomes (e.g., toxicity, allergy, therapeutic failure) for each agent; and state duration of therapy for agents where therapeutic failure is claimed. |
Quantity Limit Exceptions
Definitions and Statutory Notes
Background and Purpose
This form is used to request access to medications that are not on the plan’s formulary or that are subject to utilization management requirements (prior authorization, step therapy, or quantity limits). Providers must complete the prescriber section and attach necessary clinical notes to support the request.
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