Prior authorization appeal tool

Step {{index + 1}} of {{steps.length}}

Dermatologic disease with ICD-10 diagnosis code

Name of drug

Alternative treatment drug options

For step therapy protocols, select drug/treatment the insurance company is requiring you to prescribe your patient as an alternative treatment (skip if not applicable).

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Patient name

Patient health insurance identification number

Patient date of birth

Date of prior authorization

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I have previously prescribed this patient the following therapies (optional):

Prescribed from {{ convertDatePickerDate(medication.startDate) }} to {{ convertDatePickerDate(medication.endDate) }}

Reasoning: {{ medication.stopReason }}

Name of medication

Dates prescribed

From

Reason for stopping medication

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Cards TK

Prior authorization appeal tool

{{ steps[index] }}

Dermatologic disease with ICD-10 diagnosis code

Name of drug

Alternative treatment drug options

Name of medical director

Insurance company name

Insurance company address

Insurance company city, state, zip

Patient name

Patient health insurance identification number

Patient date of birth

Date of prior authorization

I have previously prescribed this patient the following therapies (optional):

{{ medication.medName }}

Name of medication

Dates prescribed

Reason for stopping medication

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Prior authorization appeal tool

{{ steps[index] }}

Dermatologic disease with ICD-10 diagnosis code

Name of drug

Alternative treatment drug options

Name of medical director

Insurance company name

Insurance company address

Insurance company city, state, zip

Patient name

Patient health insurance identification number

Patient date of birth

Date of prior authorization

I have previously prescribed this patient the following therapies (optional):

{{ medication.medName }}

Name of medication

Dates prescribed

Reason for stopping medication

Related Academy Resources