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Formulary Exceptionprior Authorization Request Form

Use a Formulary ExceptionPrior Authorization Request Form 2019 template to make your document workflow more streamlined.

What this formulary exception request does

The Formulary Exceptionprior Authorization Request Form documents a prescriber’s request for coverage of a medication that falls outside a health plan’s formulary. The requester identifies the patient, plan, medication, diagnosis, treatment history, and clinical reason for the exception, then supplies supporting records and required certifications. A completed request gives the payer a structured basis for review; it does not itself guarantee approval or replace the payer’s policy. With signNow, a healthcare team uploads the form, reviews detected fields, assigns signers, collects signatures, and preserves the completed record with an Audit Trail.

Who uses this authorization request

Healthcare providers

Healthcare providers use the Formulary Exceptionprior Authorization Request Form to document why a non-formulary medication is clinically appropriate, attach supporting records, and route signatures to the prescriber, patient, and payer representatives. HIPAA safeguards, consent documentation, and an exportable audit trail matter because the request may contain protected health information.

Pharmacy and payer teams

Pharmacy and benefits teams use the request to coordinate payer review, verify medication details, and preserve the signed decision record. They should limit access to assigned personnel, confirm patient identifiers, and retain the authorization materials under the organization’s HIPAA and state-record policies.

Features that support exception requests

signNow features can organize the clinical request, signature sequence, and evidence record without deciding whether the payer should approve the medication exception.

Field detection

Auto-detected fields help identify patient, medication, prescriber, payer, and signature areas after upload, while manual placement lets staff correct fields before sending the request for authorization.

Role routing

Assigned roles keep the prescriber, patient, and payer-facing participants connected to the fields they must complete, reducing accidental edits to clinical justification and member information.

Audit trail

The Audit Trail records access, signing events, timestamps, and document activity, giving healthcare administrators evidence of how the completed request moved through review.

Reusable templates

Templates preserve recurring request fields and routing instructions, helping staff prepare repeated formulary exception submissions without rebuilding the workflow for every patient.

Mobile signing

Mobile apps let authorized staff and signers review or complete the request away from a desk, subject to the organization’s device and privacy controls.

HIPAA support

HIPAA-compliant use with a required BAA supports workflows involving protected health information when the organization configures access, retention, and disclosure practices appropriately.

How to complete the authorization request

Use signNow to prepare the formulary exception request, route required signatures, and preserve the completed authorization record for payer follow-up.

  • Upload documents:

     Upload the completed request and supporting clinical documentation.

  • Check fields:

     Review detected fields and add missing signer or date fields.

  • Assign signers:

     Send the request to the prescriber, patient, or payer representative.

  • Archive records:

     Complete signatures, download the final copy, and retain the audit trail.

Recommended request workflow settings

Configure the formulary exception workflow around signer identity, clinical record protection, audit evidence, and the applicable healthcare retention rule.

SettingRecommendation
Authentication methodEmail link with SMS OTP
Signature typeTyped or drawn eSignature
Audit trailExport after completion
Document retention6 years under 45 CFR 164.530(j)
EncryptionAES-256 at rest and TLS in transit
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What the audit trail records

For a formulary exception request, signNow records signer access, document events, and completion evidence separately from the clinical reasoning itself.

01

Open request:

 The signer opens the request through the assigned email or signing link.
02

Authenticate signer:

 The configured authentication method records how signer access was verified.
03

Capture timestamp:

 Each action receives a recorded date and time.
04

Hash document:

 The completed document receives a cryptographic integrity record.
05

Seal history:

 The signing history is sealed against unnoticed document changes.
06

Export evidence:

 Authorized staff retrieve or export the audit trail for review.

Signer authentication and certificates

PKI support:

 PKI supports certificate-based identity

X.509 certificates:

 X.509 certificates identify digital signers

Two-factor authentication:

 Two-factor authentication strengthens signer access

SMS OTP:

 SMS OTP verifies a mobile number

ID verification:

 ID verification adds identity proofing

Signing evidence:

 Audit timestamps preserve signing evidence

Find and fill out the correct formulary exceptionprior authorization request form

airSlate SignNow helps you fill in and sign documents in minutes, error-free. Choose the correct version of the editable PDF form from the list and get started filling it out.

VersionsForm popularityFillable & printable
CVS Caremark 106-37207A 20214.8 Satisfied (2180 Votes)
CVS Caremark 106-37207A 20204.8 Satisfied (156 Votes)
CVS Caremark 106-37207A 20194.7 Satisfied (167 Votes)
CVS Caremark 106-37207A 20174.7 Satisfied (168 Votes)

Privacy pitfalls in authorization requests

  • Including a patient’s full diagnosis or medication history in an email attachment can expose protected health information beyond the authorization team.
  • Failing to capture patient consent before sharing clinical justification can undermine the request’s privacy documentation and delay payer review.
  • Leaving the completed request accessible to every workspace user may expose identifiers, prescriber details, and payer determinations unnecessarily.
  • Using an unsigned clinical attachment or mismatched patient identifier can cause the payer to reject the formulary exception request.

Retention practices for authorization records

Preserve the request, evidence, signatures, and audit history together so formulary exception decisions remain reviewable without exposing unnecessary patient information.

Apply the six-year HIPAA retention rule

Keep the completed request, supporting clinical notes, payer correspondence, and signed consent together. For HIPAA-covered records, retain documentation for 6 years from creation or last effective date under 45 CFR 164.530(j). Apply any longer state or payer rule after checking the governing policy.

Export the audit trail with each request

Export the signNow Audit Trail after every completed request and preserve it with the final PDF. The export should show signer identity, authentication events, timestamps, and document activity, giving reviewers a reproducible record of authorization submission and approval history.

Archive protected records with controlled access

Store completed authorization requests in an access-controlled repository with encryption at rest and in transit. Separate patient identifiers from operational reporting where possible, restrict downloads to assigned staff, and document each approved retention or deletion action.

Use precise, privacy-conscious file naming

Use a consistent file name containing patient or case ID, medication, payer, request status, and completion date. Avoid placing unnecessary diagnoses in filenames, and verify that the retained copy opens correctly before closing the authorization record.

Processing stages for the request

No universal payer turnaround period is provided for this form; completion depends on accurate preparation, signer availability, and the health plan’s review process.

01

Prepare the request

Confirm patient, medication, payer, and clinical justification fields before sending.
02

Deliver to signers

Assign the prescriber, patient, or other required signer through signNow.
03

Collect signatures

Signers complete assigned fields after reviewing the clinical information.
04

Complete and archive

Download the completed request and export its Audit Trail.

Integrations for authorization operations

Connect the signed request with healthcare operations through named CRM, cloud storage, workflow, and enterprise systems while preserving access controls for protected health information.

Salesforce
Procore
Zapier
Microsoft Teams
Hub spot
Box
Microsoft

Pricing for authorization workflows

For this formulary exception request, signNow’s verified pricing is shown first; competitor prices and features remain unverified where the available source provides no confirmed value.

FeaturessignNowDocuSignAdobe SignPandaDocDropbox Sign
Starting annual price$8/user/month, BusinessNot verifiedNot verifiedNot verifiedNot verified
Free trial7 days, no card requiredNot verifiedNot verifiedNot verifiedNot verified
Bulk sendBusiness Premium includes itNot verifiedNot verifiedNot verifiedNot verified
Audit trailIncluded in BusinessNot verifiedNot verifiedNot verifiedNot verified
HIPAA complianceAvailable with BAANot verifiedNot verifiedNot verifiedNot verified
Signature invite limit100 per user annuallyNot verifiedNot verifiedNot verifiedNot verified

Troubleshooting formulary exception requests

Resolve field, privacy, plan, and evidence questions before sending a formulary exception request through signNow.

On signNow’s Business plan, upload the formulary exception request, place fields manually if auto-detection misses one, and send it to each assigned signer. Business includes templates, audit trails, and legally binding eSignatures at $8 per user monthly when billed annually.

A patient-facing request may require electronic-record consent under 15 U.S.C. §7001(c). Provide the consumer disclosure, confirm electronic access, and explain withdrawal procedures before signing; signNow can capture the signature and audit history but cannot replace the required disclosure process.

HIPAA compliance requires a business associate agreement when signNow handles protected health information for a covered entity. The signNow ground truth identifies HIPAA compliance as requiring a BAA; confirm the agreement and configure access controls before uploading clinical justification.

Business Premium is the signNow plan that includes bulk send, while Business does not. If a clinic sends individualized requests repeatedly, verify patient-specific fields before using bulk workflows and avoid reusing clinical information across recipients.

The signNow Business plan includes 100 signature invites per user per year, with overage fees. The Site License uses $1.50 per signature invite and is intended for usage-based volume; review current plan terms before estimating recurring authorization costs.

For an evidentiary record, retain the completed request and exported Audit Trail together. ESIGN and UETA support electronic signatures when intent, consent, attribution, and record reproduction are established; signNow’s audit history documents workflow events but does not determine medical necessity.

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