Form 61-211 "Prescription Drug Prior Authorization or Step Therapy Exception Request Form - Express Scripts"

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Download Form 61-211 "Prescription Drug Prior Authorization or Step Therapy Exception Request Form - Express Scripts"

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Page 1 of 2
P
D
P
A
S
T
E
R
F
RESCRIPTION
RUG
RIOR
UTHORIZATION OR
TEP
HERAPY
XCEPTION
EQUEST
ORM
Plan/Medical Group Name: ________________________________
Plan/Medical Group Phone#: (_______)
Plan/Medical Group Fax#: (_______)________________________
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
First Name:
Last Name:
MI:
Phone Number:
Address:
City:
State:
Zip Code:
Date of Birth:
Male
Circle unit of measure
Allergies:
Female
Height (in/cm): ______Weight (lb/kg):______
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:
Specialty:
Address:
City:
State:
Zip Code:
Requestor (if different than prescriber):
Office Contact Person:
NPI Number (individual):
Phone Number:
DEA Number (if required):
Fax Number (in HIPAA compliant area):
Email Address:
Medication / Medical and Dispensing Information
Medication Name:
New Therapy
Renewal
Step Therapy Exception Request
If Renewal: Date Therapy Initiated:
Duration of Therapy (specific dates):
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:
Oral/SL
Topical
Injection
IV
Other:
Administration Location:
Patient’s Home
Long Term Care
Physician’s Office
Home Care Agency
Other (explain):
Ambulatory Infusion Center
Outpatient Hospital Care
Revised 12/2016
Form 61-211
Page 1 of 2
P
D
P
A
S
T
E
R
F
RESCRIPTION
RUG
RIOR
UTHORIZATION OR
TEP
HERAPY
XCEPTION
EQUEST
ORM
Plan/Medical Group Name: ________________________________
Plan/Medical Group Phone#: (_______)
Plan/Medical Group Fax#: (_______)________________________
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
First Name:
Last Name:
MI:
Phone Number:
Address:
City:
State:
Zip Code:
Date of Birth:
Male
Circle unit of measure
Allergies:
Female
Height (in/cm): ______Weight (lb/kg):______
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:
Specialty:
Address:
City:
State:
Zip Code:
Requestor (if different than prescriber):
Office Contact Person:
NPI Number (individual):
Phone Number:
DEA Number (if required):
Fax Number (in HIPAA compliant area):
Email Address:
Medication / Medical and Dispensing Information
Medication Name:
New Therapy
Renewal
Step Therapy Exception Request
If Renewal: Date Therapy Initiated:
Duration of Therapy (specific dates):
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:
Oral/SL
Topical
Injection
IV
Other:
Administration Location:
Patient’s Home
Long Term Care
Physician’s Office
Home Care Agency
Other (explain):
Ambulatory Infusion Center
Outpatient Hospital Care
Revised 12/2016
Form 61-211
Page 2 of 2
P
D
P
A
S
T
E
R
F
RESCRIPTION
RUG
RIOR
UTHORIZATION OR
TEP
HERAPY
XCEPTION
EQUEST
ORM
Patient Name:
ID#:
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.
1. Has the patient tried any other medications for this condition?
YES (if yes, complete below)
NO
Medication/Therapy
Duration of Therapy
Response/Reason for Failure/Allergy
(Specify Drug Name and Dosage)
(Specify Dates)
2. List Diagnoses:
ICD-10:
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
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 necessary 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 transmission contain confidential health information that is legally privileged. 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 (
)
__________________
Approved
Denied
Comments/Information Requested:
Revised 12/2016
Form 61-211
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