Instructions: Please fill out all applicable sections on both pages completely andlegibly. Attact any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization request.
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 neende to establish diagnosis, or evaluate response. Please provide any additional clinical information or comments pertinent to this request for coverage (e.g. formulary tier exceptions) or required under state and federal laws.
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