Prior Authorization Request (Dermatology Medication)

Date: [Date of letter]
To: [Payer name], Utilization Management / Pharmacy Services
Fax/Portal: [Fax number or portal if known]
Request Type: [Initial PA / Reauthorization / Step-Therapy Override / Formulary Exception / Urgent-Expedited]

Patient: [Full name], DOB: [DOB], Member ID: [Member ID]
Prescriber: [Name, credentials], NPI: [NPI], Practice: [Practice name], Phone: [Phone], Fax: [Fax]

Executive Summary

• [Requested medication: generic (brand) — dose, route, frequency, duration requested] (Include loading and maintenance doses if applicable.)
• [Diagnosis with ICD-10 code and clinical subtype; date of diagnosis and disease duration]
• [Current severity with objective metrics and high-impact site involvement; functional impact if documented]
• [Prior therapies failed, intolerated, or contraindicated — use dated, specific entries]
• [Baseline safety screening status and monitoring plan confirmation]

Diagnosis and Severity

Diagnosis: [Condition] — ICD-10: [Code]; Date of diagnosis: [Date]; Disease duration: [Duration]

Clinical subtype/phenotype: [Subtype and anatomic distribution if applicable]

Objective severity: [BSA: X% (date); PGA/IGA: X (date); condition-specific indices as applicable: EASI/SCORAD for atopic dermatitis, PASI for psoriasis, acne severity with scarring status, HS lesion counts and flare frequency, or other validated tools] (If formal scoring not obtained, document available measures and note "formal score not obtained.")

• High-impact sites involved: [hands / feet / face / scalp / genitals / intertriginous areas / nails / eyelids] (Include only if applicable.)
• Functional impact: [Work/school disruption, sleep impairment, ADL limitations, occupational restrictions, pain, recurrent infections] (Include only if documented; quantify where possible.)
• Diagnostics: [Biopsy date and result if applicable]; Photographs attached: [yes / no]

Requested Medication

Medication: [Generic name] ([Brand name])
Indication: [On-label / Off-label] (If off-label, note rationale provided below.)
Dose/Route/Frequency: [Dose, route, frequency; include loading dose and titration if applicable]
Quantity/Days Supply/Refills: [Per payer requirements]
Administration Site: [Home / Clinic or infusion center] (Include if relevant to benefit determination.)
Drug Codes: [NDC and/or HCPCS J-code if required]
Weight-based dosing: [Weight and date] (Include only if applicable.)

Prior and Current Therapies

(Document all pertinent therapies. Use approximate month/year if exact dates unknown and label as approximate. Include phototherapy details if applicable.)

Drug/Therapy (Class)	Dose/Route/Frequency	Dates (Start–Stop)	Response	Reason Stopped
[Drug name and class]	[Dose/route/frequency]	[Dates or duration] (Mark approximate if needed.)	[None / Partial / Inadequate]	[Lack of efficacy / Adverse event / Contraindication / Intolerance]
[Additional therapies as needed]

Contraindications to payer-preferred alternatives: [Specific contraindications: pregnancy risk, uncontrolled comorbidities, infection risk, lab abnormalities, prior malignancy, drug interactions, prior serious adverse reactions]

Safety Assessment

Why Alternatives Are Not Appropriate: [Specific contraindications or treatment-limiting adverse effects to payer-mandated alternatives; objective rationale tied to patient factors]

Safety for Requested Medication: [Infection history if relevant; pregnancy status and contraception plan when applicable; key comorbidities affecting monitoring; immunization status if needed before immunomodulator initiation] (Document known information only; specify what will be obtained before initiation if required.)

Baseline Labs and Screening

(Include only tests relevant to the requested medication and payer criteria. If a test is pending, state expected completion date; medication will not start until results reviewed.)

• TB Screening: [Test type, date, result] (Include only when clinically indicated; routine TB screening is not required for most IL-17/IL-23 inhibitors per current guidelines.)
• Hepatitis B/C: [Date, result]
• CBC/CMP/LFTs: [Date, key values]
• Pregnancy Test: [Date, result] (Include when applicable.)
• Other Required Tests: [As specified by payer criteria]

REMS: [Program name; patient and prescriber enrollment status; testing and counseling documentation plan; compliance tracking] (Include only if medication requires REMS enrollment.)

Medical Necessity Rationale

(Provide concise synthesis using dated, objective facts documented elsewhere in this letter.)

[Why the requested medication is appropriate for the diagnosis subtype and severity, tied to objective measures and high-impact site involvement]

[Why formulary-preferred options are insufficient or unsafe, based on specific prior therapy outcomes, contraindications, or intolerance]

[Risks of treatment delay: disease progression, functional decline, infection, scarring, hospitalization risk] (Include only items supported by documentation.)

[Patient-centered factors: route preference, adherence feasibility, ability to attend phototherapy, caregiver support] (Include only if documented.)

(For reauthorization: Summarize objective improvement since initiation with dated metrics; explain why continuation is necessary and expected consequences if therapy stopped.)

Monitoring Plan

• Before Initiation: [Confirm baseline labs/screening reviewed; vaccinations addressed if required; counseling completed; list pending items with expected dates]
• Ongoing: [Lab monitoring schedule; clinical follow-up interval; objective metrics to reassess; infection surveillance approach]
• Discontinuation Criteria: [Serious adverse events; defined lack of response timepoint; relevant lab thresholds]

Attachments

• 1. [Most recent dermatology note with severity documentation — date]
• 2. [Photographs — date] (if attached)
• 3. [Pathology report — date] (if applicable)
• 4. [Relevant lab results — dates]
• 5. [Prior therapy documentation — dates]
• 6. [Guideline or literature excerpt] (if off-label or payer-requested)

(Per HIPAA minimum necessary requirements, only targeted relevant records are included.)

Closing

Please approve [medication] for [duration] for [patient name] for the medical necessity documented above.

For Peer-to-Peer Review: [Contact name], Phone: [Direct number], Availability: [Days/times]

Signature: [Signature], [Printed name, credentials], NPI: [NPI], Date: [Date]

Expedited Review Justification

(Include only if urgent/expedited review is requested.)

[Specific harm if delayed: rapidly progressive disease, severe pain, infection risk, inability to work/attend school, hospitalization risk]; Requested decision timeframe: [Timeframe]

Off-Label Use Justification

(Include only if requested use is off-label.)

[Statement that use is off-label; supporting guideline or peer-reviewed evidence with citation; explanation of why on-label alternatives are inappropriate for this patient based on documented history]