Prescription Prior Authorization Request Form

PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST OR STEP THERAPY EXCEPTION REQUEST FORM

Plan/Medical Group Name: Contra Costa Health Plan
Plan/Medical Group Fax#: (866)205-8014

Plan/Medical Group Phone#: (877)800-7423

Non-urgent

Exigent circumstances

Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization or step-therapy exception request. Information contained in this form is Protected Health Information under HIPAA.

Patient information

Member Id:

First Name:

Last Name:

MI:

Phone:

Address:

City:

State:

Zip Code:

Date of Birth:

Male

Female

Circle unit of measure

Height

Units

Weight

Units

Allergies:

Patient's Authorized Representative (if applicable):

Authorized Representative Phone Number:

Insurance information

Primary Insurance Name:

Patient ID Number:

Secondary Insurance Name:

Patient ID Number:

Prescriber information

First Name:

Last Name:

Speciality:

Address:

City:

State:

Zip Code:

Requestor (if different than prescriber):

Office Contact Person:

NPI Number (individual):

Phone Number:

DEA Number (if required):

Fax (in HIPPA compliant area):

Email Address:

Medication / Medical and Dispensing information

Medication Name:

New Therapy Renewal Step Therapy Exception

If renewal:

Date Therapy Initiated

Duration of Therapy (specify days)

How did the patient receive the medication?

Paid under insurance Name: Prior Auth Number (if known):

Other (explain):

Dose/Strength:

Frequency:

Length of Therapy/#Refills:

Quantity:

Administration:

Patient Name:

ID#:

Instructions: Please fill out all applicable sections completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization or step therapy exception request.

1. Has the patient tried any other medications for this condition? YES (if yes, complete below)NO

Medication/Therapy

(Specify Drug Name and Dosage)

Duration of Therapy

(Specify Days)

Response/Reason for Failure/Allergy

2. List Diagnoses:

ICD-10:

Invalid ICD Code

3. Required clinical information - Please provide all relevant clinical information to support a prior authorization or step therapy
exception request review.

Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose and if patient has any contraindications for the health plan/insurer preferred drug. Lab results with dates must be provided if needed to establish diagnosis, or evaluate response. Please provide any additional clinical information or comments pertinent to this request for coverage, including information related to exigent circumstances, or required under state and federal laws.

- Attachments are optional. If needed you can upload and attach files to this request.
  The following file extensions are allowed: ".pdf, .doc, .docx, .xls, .xlsx, .ppt, .txt"
  Files must be 3 MB (3,000,000 bytes) or less.
- Attachment Type:
- Select a file to upload:

Attestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information to verify the accuracy of the information reported on this form.

Prescriber Signature or Electronic I.D. Verification:

Date:

Confidentiality Notice: The documents accompanying this transaction contain confidential health information that is legally priviledged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately (via return FAX) and arrange for the return or destruction of these documents.

Plan/Insurer Use Only: Date/Time Request Received by Plan/Insurer:

Date/Time of Decision:

Fax Number:

ApprovedDeniedAdditional info Requested

Comments/Information Requested:

Physician's Office	Patient's Home	Ambulatory Infusion Center	Home Care Agency
Long Term Care	Outpatient Hospital Care	Other (explain):