Prior Authorization Request Letter (Psychiatric Medication)

Date: [Date of submission]

To: [Plan/PBM name], Utilization Management Department, [Address or fax]

Patient: [Full name], DOB: [Date of birth], Member ID: [Member ID]

Prescriber: [Prescriber name], [Credentials] (NPI: [NPI]); [Practice name]; Direct Phone: [Phone]; Fax: [Fax]

PA Reference Number: [Reference number, if assigned]

RE: [Prior Authorization Request / Step-Therapy Override Request / Tier Exception Request / Quantity-Limit Exception Request / Formulary Exception Request] – [Medication generic (Brand)] for [Diagnosis/Indication], Member ID: [Member ID]

Request Summary

• Medication requested: [Generic (Brand)], [formulation]
• Dose and schedule: [Current or proposed dose and frequency]
• Quantity and days' supply: [Quantity] for [Days' supply]
• Duration: [Initial authorization period with reassessment timeframe / Continuation of stable regimen since date]
• Diagnosis: [ICD-10 code(s)] – [Diagnosis name(s)]
• Request type: [PA / step-therapy override / tier exception / quantity-limit exception / formulary exception]
• Expedited review: [Clinical justification for why delay risks harm] (Only include if clinical urgency exists)

(If any information is not yet available, state "pending" with plan to obtain.)

Clinical Summary

[Primary psychiatric diagnosis relevant to request, time course, current treatment setting, and pertinent psychiatric history directly relevant to urgency or medical necessity. Include relevant medical comorbidities affecting medication selection. Label information sources explicitly as chart-documented, patient-reported, external records, or collateral.] (Keep to 2–4 sentences.)

Target Symptoms and Severity

• Target symptoms: [Discrete symptoms for treatment]
• Severity indicators: [Standardized rating scale name, score, and date; or structured frequency/intensity description] (Prefer quantified descriptors over vague terms)
• Functional impact: [Impact on work/school, ADLs, social functioning, housing stability, ED utilization]
• Risk indicators: [Relevant safety concerns with characteristics and dates] (Only include if clinically relevant and documented)

Prior Treatment History

(List relevant prior medication trials including formulary-preferred agents. Label unverified items as patient-reported. If extensive, summarize here and attach full table.)

Agent (formulation)	Dose range / max	Duration	Response	Adverse effects	Reason discontinued	Source
[Medication (formulation)]	[Dose range or max tolerated]	[Duration or reason inadequate]	[None / partial / good]	[Adverse effects and severity]	[Ineffective / intolerable / contraindication / interaction / cost]	[Chart-documented / patient-reported / external records]

Non-pharmacologic treatments: [Psychotherapy modality, duration, outcome; IOP/PHP/ECT/TMS if applicable] (Include when relevant to severity or comprehensive care)

Why Alternatives Are Not Appropriate

(Address payer formulary logic directly. Organize by alternative agent or class with patient-specific evidence.)

• [Alternative agent or class]: [Not effective / not tolerated / not safe / not clinically appropriate] – [Documented adverse reactions, contraindications based on comorbidities, significant drug-drug interactions, prior failure with dates and trial adequacy, or clinical rationale for dose/quantity exception]

(When extrapolating from class-wide issues or contraindications, label as clinical judgment and provide rationale.)

Clinical Rationale for Requested Medication

[Why this medication is expected to be effective for target symptoms in this patient. Address fit to clinical presentation, relevant pharmacologic properties, why formulation matters if applicable, and any prior positive response to this medication or related agents.]

Off-label use: This is an off-label use. [Evidence basis: guideline support, peer-reviewed data, compendia support. Explanation of why on-label alternatives are inappropriate for this patient.] (Include only if indication is off-label or may be disputed by payer)

Requested Regimen

• Starting dose and titration: [Starting dose] with [titration schedule] to [target dose]
• Route/formulation: [Route and formulation-specific instructions]
• Quantity / days' supply / refills: [Quantity], [Days' supply], [Refills]
• Trial duration: [Duration before efficacy assessment] (For continuation requests: document stability on regimen and risks of interruption)

Monitoring and Safety Plan

• Baseline completed: [Relevant baseline assessments with dates and notable results] (If pending, specify orders and expected date)
• Planned monitoring: [Schedule specific to medication class]
• Safety counseling provided: [Relevant precautions and warnings discussed]
• Adherence and risk mitigation: [PDMP check date, UDS policy, controlled substance agreement as applicable]
• Care coordination: [Planned collaboration with other providers as warranted]

(Include only monitoring pertinent to the requested medication class.)

Expected Outcomes and Reassessment

• Clinical targets: [Measurable goals tied to symptoms]
• Functional targets: [Measurable functional improvement goals]
• Timeframe: [Interval for efficacy assessment]
• Continuation criteria: [Criteria for continuation vs. discontinuation]
• Contingency plan: [Plan if inadequate response]

Enclosures

• [List attachments: medication trial history table, rating scale summary, pertinent lab results, relevant discharge summary or external records]

(Do not include psychotherapy notes or detailed session content.)

Closing

I am requesting approval for [Medication generic (Brand)] as outlined above for [Diagnosis/Indication]. Please contact me directly at [Direct phone] for additional information or to arrange a peer-to-peer review. I am available [best days/times]. Thank you for your timely consideration.

Sincerely,

[Prescriber name], [Credentials] (NPI: [NPI])
[Practice name] • [Practice address]
Phone: [Phone] • Fax: [Fax]
Date: [Date signed]

(Use explicit placeholders with timelines when information is missing. Label evidence sources throughout. Do not infer diagnoses, severity, or history not stated. Label unverified prior trials as patient-reported. Omit expedited review language when no urgency. Omit off-label subsection when not applicable. Keep body to 1–2 pages; move lengthy trial details to attachment.)