Prior Authorization Request (Medication)

Document Header

Request Date: [Request date]
Request Type: [Initial / Continuation or Renewal / Exception Request]
Urgency: [Standard / Expedited]
Payer/PBM: [Plan name and reference number if resubmission] (Omit line if unknown)

Patient Information

Patient Name: [Full name as on insurance card]
Date of Birth: [Date of birth]
Member/Subscriber ID: [Member ID] (If missing, insert "[Member ID required]")
Group Number: [Group number] (If missing, insert "[Group number required]")

Prescriber Information

Prescriber: [Name and credentials]
NPI: [NPI]
Practice/Facility: [Practice or facility name and address]
Phone/Fax: [Phone] / [Fax]
Contact for Follow-up: [Name/role and direct contact] (Include only if provided)

Site of Care: [Facility name, NPI, administration setting, address] (Include for infused or specialty-administered medications; omit otherwise)

Medication Request

Medication: [Generic name] ([Brand name])
Strength/Dose/Route/Frequency: [Strength] / [Dose] / [Route] / [Frequency] (If any element is missing, insert placeholder—do not submit until complete)
Quantity and Duration: [Quantity per fill] for [Days supply or duration]
Start Date: [Start date or "upon approval"]
Clinical Status: [New start / Continuation]
Original Start Date: [Date] (Include for continuation requests only)
Most Recent Fill/Administration Date: [Date] (Include for continuation requests only)
Billing Codes: [NDC, HCPCS J-code, or CPT code] (Include only if relevant for billing)

Diagnosis and Indication

Primary Diagnosis: [Condition name] ([ICD-10 code])
Disease Subtype/Course: [Subtype, course, or severity classification] (Include if relevant)
Label Status: [On-label / Off-label] (If off-label, state evidence basis in Medical Necessity Rationale)

Diagnostic Framework/Criteria: [Named criteria or guideline] (Briefly state how criteria are met; distinguish objective evidence from patient-reported history)

• Objective evidence: [Pertinent imaging, labs, exam findings with dates]
• Patient-reported history: [Pertinent symptom history supporting diagnosis]
• Provisional status: [Provisional diagnosis and pending confirmatory testing] (Include only if diagnosis not yet confirmed; omit otherwise)

Clinical Severity and Functional Impact

(Use time-anchored metrics with specified measurement window. For continuation requests, include baseline pre-treatment and current on-therapy status.)

• Time window: [Measurement period, e.g., past 3 months]
• Symptom frequency/severity/duration: [Quantified metrics]
• Healthcare utilization: [ER visits, hospitalizations with dates] (Include if applicable)
• Functional impact: [Work/school impairment, ADL limitations, days missed]
• Validated scale scores: [Scale name, score, date] (Include if available)
• Baseline severity prior to treatment: [Pre-treatment metrics] (For continuation requests)
• Current status on therapy: [Current metrics showing response or stability] (For continuation requests)

Prior Therapy History

(Document all relevant prior and payer-preferred therapies. Do not infer dose, duration, or outcomes—mark as unknown if uncertain. Label source as "per chart" or "per patient report.")

Medication (class)	Dates (start–stop)	Dose Achieved	Duration	Outcome	Reason Stopped	Source
[Medication name (class)]	[Date range]	[Dose]	[Duration]	[Failed—ineffective / Failed—intolerant / Contraindicated / Not tried]	[Specific reason]	[Per chart / Per patient report]

(Add rows for each prior therapy. Include all payer-preferred alternatives.)

Step Therapy/Exception Rationale: (Include if requesting exception or step-therapy override. Explicitly address each payer-preferred alternative and document why it is not appropriate—failure, intolerance, contraindication, or clinical exception.)
[Payer-preferred alternative and rationale for each]

Relevant Comorbidities and Safety Considerations

(Include only conditions that materially affect medication choice, safety, or monitoring. Omit this entire section if none apply.)

• Allergies/serious prior drug reactions: [Allergen, reaction, severity]
• Pregnancy/reproductive plans: [Status and relevant counseling or testing]
• Organ impairment: [Renal/hepatic/cardiac status with relevant labs and dates]
• Infection/immunosuppression risk: [TB, hepatitis, HIV screening results with dates; vaccination status]
• Other relevant conditions: [Cardiovascular or medication-specific risk factors]
• Required safety screening: [Completed or pending tests with dates and results]

Supporting Evidence Summary

(Briefly list key objective findings supporting diagnosis or payer criteria. Reference attachments for full reports.)

• Imaging: [Modality, date, concise impression]
• Laboratory: [Test, date, value, interpretation]
• Clinical findings: [Exam finding, date, interpretation]

Medical Necessity Rationale

(Write 1–3 concise paragraphs synthesizing: confirmed diagnosis, severity, and functional impairment or healthcare burden; why formulary alternatives are not appropriate based on documented failures, intolerances, or contraindications; expected clinical benefit and risks if treatment is delayed or denied. If off-label, state and summarize supporting evidence.)

[Medical necessity rationale]

Urgent/Expedited Processing Justification

(Include only if Expedited is selected above. Document time-sensitive clinical risk, why standard timeframe is inappropriate, and dates of recent acute events. Omit this entire section for standard requests.)

[Justification with dates of recent events]

Attachments Index

(List only documents actually included. Remove items not attached.)

• [ ] Recent progress note(s) [date range]
• [ ] Medication history and prior trial documentation
• [ ] Imaging reports
• [ ] Lab results
• [ ] Patient diary or symptom log
• [ ] Completed payer forms
• [ ] Other: [Specify]

Attestation and Signature

The information provided is accurate to the best of my knowledge and supported by the medical record.

Prescriber Signature: _______________________________
Name/Credentials: [Printed name and degree(s)]
NPI: [NPI]
Date: [Date]
Peer-to-peer availability: [Direct contact number and availability window] (Include if provided)