Prior Authorization Request (Antiseizure Medication)

Administrative Header

Patient: [Full name], DOB: [DOB], Member ID: [Member ID]
Prescriber: [Name], [Credentials]; NPI: [NPI]; Specialty: [Specialty]; Practice Address: [Address, City, State, ZIP]; Phone: [Phone]; Fax: [Fax]
Request Type: [new start / continuation] | Urgency: [standard / expedited / urgent] | Exception: [none / formulary exception / step-therapy override / quantity-limit exception]
PA Contact: [Staff name], Callback: [Phone number]

Medication Requested

Medication	[Generic name] ([Brand name if relevant])
Formulation / Strength	[Formulation]; [Strength]
Dose and Schedule	[Maintenance dose and frequency] (Include titration plan if applicable)
Quantity and Days' Supply	[Quantity per fill] for [Days' supply]
Duration	[indefinite / time-limited trial]; Reassessment: [Timeframe]
Indication	[ICD-10 code(s)]: [Plain-language diagnosis]
Current Concomitant ASMs	[Current antiseizure medications with doses; include rescue therapy if applicable]

Medical Necessity Summary

[Concise 3–6 sentence summary addressing: epilepsy diagnosis and seizure type(s); current seizure burden and functional/safety risks; prior therapies tried and outcomes (ineffective, intolerable, or contraindicated); why the requested medication is necessary now; expected consequences without approval such as breakthrough seizures, hospitalization risk, or loss of function.]

Source: [in-system documentation / patient-reported / caregiver-reported / outside-record review]

Epilepsy Diagnosis and Seizure Classification

Primary epilepsy diagnosis: [Diagnosis] (ICD-10: [Code]); Onset: [Month/Year or approximate]
Etiology/syndrome: [structural / genetic / metabolic / infectious / immune / unknown; specific syndrome if applicable]

Seizure types (Classify using ILAE terminology only to the extent supported by documentation):

• Type 1: Onset [focal / generalized / unknown]; Awareness [aware / impaired awareness] (if focal); Features [motor / nonmotor]; Evolution [focal to bilateral tonic-clonic] (if applicable)
• Type 2: [Add additional types as applicable with the same structure]

Diagnostic uncertainty: [Describe any uncertainty such as possible PNES, evaluation completed to date, and current working diagnosis] (Omit if not applicable)

Source: [in-system documentation / outside-record review]

Seizure Burden and Severity

• Frequency by seizure type: [Type 1: numeric rate or category]; [Type 2: rate or category]
• Last seizure: [Date or approximate date by type]; Baseline frequency before current regimen: [Frequency by type] (if relevant)
• Clusters/Status epilepticus: [History with dates, or "None"]; Rescue medication use: [Agent and frequency]
• Healthcare utilization: [Seizure-related ED visits/hospitalizations in past 12 months with dates]
• Clinical consequences: [Injuries, falls, aspiration risk, supervision needs, work/school impairment, driving restrictions]
• Treatment goals: [seizure freedom / reduction by target % or frequency / reduction in convulsive seizures / improved tolerability / simplified regimen]

Source: [patient-reported / caregiver-reported / in-system documentation / outside-record review]

Prior Antiseizure Medication Trials

Medication	Dates/Duration	Max Dose Achieved	Serum Level	Response	Adverse Effects	Reason for Discontinuation	Adequacy
[Drug 1]	[Dates or duration]	[Max daily dose; mg/kg for pediatrics]	[Level and date / not obtained]	[no benefit / partial benefit / seizure freedom]	[Specific effects / none]	[inefficacy / intolerance / contraindication / interaction / nonadherence / access-cost]	[Adequate / Inadequate]; [Brief rationale]
[Drug 2]	[Dates or duration]	[Max daily dose]	[Level / not obtained]	[Response]	[Adverse effects]	[Reason]	[Adequacy]
[Additional rows as needed]

Trial adequacy summary: [State whether prior trials were appropriate for seizure type, used at adequate dose/duration, and adherence evidence]

Step therapy mapping: [Payer Step 1] → [Corresponding trial and outcome]; [Payer Step 2] → [Trial and outcome] (Include only if payer requires step therapy documentation)

Serious adverse reactions: [Severe rash, DRESS, hepatotoxicity, hyponatremia, severe psychiatric effects with dates; or "None documented"]

Source: [in-system documentation / pharmacy history / outside-record review / patient-reported]

Current Regimen and Response

• Current ASMs: [List each with dose, route, schedule]
• Adherence: [Good / Variable / Poor]; Evidence: [pharmacy fill history / patient report / pill counts]; Barriers: [cost / side effects / complexity / none]
• Response trend: [Compare seizure frequency before and after recent regimen changes]
• Why current regimen is insufficient: [persistent seizures / unacceptable adverse effects / drug interactions / contraindications / unable to escalate dose]

Source: [in-system documentation / patient-reported / pharmacy data]

Rationale for Requested Medication

[Explain why this medication is appropriate for the seizure type(s)/syndrome, expected benefit based on mechanism or evidence, and why it is safer or more appropriate than alternatives given patient-specific factors (comorbidities, interaction profile, prior adverse reactions, pregnancy potential, organ dysfunction)]

• Formulary alternatives addressed: [Alternatives tried with outcomes]; [Alternatives contraindicated with patient-specific factors]
• Exception justification: [formulary exception / step-therapy override / quantity-limit exception] — [Patient-specific rationale] (Include only if requesting exception)
• Expedited review justification: [Escalating convulsive seizures / recent status epilepticus / frequent clusters / pregnancy with uncontrolled seizures / safety risk during standard review] (Include only if requesting expedited/urgent review)

Relevant Diagnostics

(Include only tests that support diagnosis, classification, or payer criteria; omit section if not applicable)

• EEG: [Date]; [routine / ambulatory / EMU]; Findings: [epileptiform discharges, focality, seizure capture]; Report attached: [yes / no]
• Neuroimaging: [MRI/CT date]; Findings: [lesion, sclerosis, malformation, or normal]; Report attached: [yes / no]
• Laboratory: [Hepatic function], [Renal function/eGFR], [Sodium], [ASM levels with dates], [Pregnancy test if applicable] (Include only values pertinent to therapy choice)

Source: [in-system documentation / outside-record review]

Patient-Specific Safety Considerations

(Include when relevant to drug choice or monitoring; omit section if not applicable)

• Reproductive considerations: [Pregnancy status/potential, contraception plan, folate supplementation, teratogenicity counseling]
• Comorbidities impacting selection: [mood disorder / cognitive sensitivity / hepatic disease / renal disease / hyponatremia risk / weight concerns / osteoporosis]
• Drug interactions: [Significant interactions with concomitant medications; enzyme induction/inhibition considerations]

Attachments

• Recent neurology note: [Attached / Not attached]
• EEG report(s): [Attached / Not attached]
• MRI/CT report(s): [Attached / Not attached]
• Discharge summaries for seizure-related admissions: [Attached / Not attached / N/A]
• Pharmacy fill history: [Attached / Not attached]
• Prior PA denial letter: [Attached / Not attached / N/A] (Include if appealing)
• Other: [Description] [Attached / Not attached]

Prescriber Attestation

I attest that the information provided is accurate and supported by the medical record. I request authorization of the above medication as medically necessary for the stated indication.

Prescriber Signature: [Signature] (electronic acceptable)
Printed Name and Credentials: [Name, Credentials]
Date: [Date]