California prescribers send this four-page form to a health plan, insurer or delegated medical group to request prior authorization of a prescription drug or an exception to step therapy. The Department of Managed Health Care and the Department of Insurance developed it as a mandatory form under SB 282 and AB 374 (2015). A plan that does not respond within 72 hours, or 24 hours in exigent circumstances, is deemed to grant the request.
The prescriber, or office staff listed as the requester, completes the patient, insurance, prescriber, medication and clinical sections, and the prescriber signs the attestation on page 4. The plan, insurer or medical group fills in only its own name and fax at the top and the Plan/Insurer Use Only box.
Enter the health plan, insurer or delegated medical group that will decide the request, with its phone and fax, unless a plan-issued copy already has them filled in. Check Non-Urgent or Exigent Circumstances. The box sets which response clock applies: 72 hours for a non-urgent request or 24 hours for an exigent one, after which an unanswered request is deemed granted.
Give the patient's first and last name, middle initial, phone, address, date of birth, sex, height, weight and allergies. If someone is acting for the patient, add the authorized representative's name and phone number. The form notes that the information on it is protected health information under HIPAA, and page 3 repeats the patient name and ID.
List the primary insurance name with the patient's ID number, and any secondary insurance with its own ID number. The plan uses this to match the request to the member's coverage, and a renewal also asks which insurer paid for the drug before.
Enter the prescriber's name, specialty and address, the requester if someone other than the prescriber is sending it, an office contact person, phone, a fax number in a HIPAA-compliant area, and email. The individual NPI is requested and the form marks the DEA number as required. The plan's reply and any request for more information come back to these contacts.
Name the medication and check New Therapy, Renewal or Step Therapy Exception Request. For a renewal, give the date therapy started and its duration, and say how the patient received the drug: paid under which insurance, the prior authorization number if known, or other. Add dose and strength, frequency, quantity, length of therapy and refills, the route (oral or sublingual, topical, injection, IV, other) and where it is given, from physician's office or infusion center to home or long-term care.
Answer yes or no. If yes, list each drug and dosage tried, the dates of therapy and the response, reason for failure or allergy. This is the core of a step therapy exception and of many prior authorization criteria, so give specific dates and outcomes rather than a general statement that other drugs failed.
List the diagnoses that support the request with their ICD-10 codes. Include every diagnosis the clinical justification in question 3 relies on, such as a condition that makes the plan's preferred drug contraindicated, so the reviewer sees the coded diagnosis next to the reasoning.
Describe symptoms, lab results with dates and the justification for starting therapy, continuing it or increasing the dose, and note any contraindication to the plan's preferred drug. Labs with dates are required when needed to establish the diagnosis or evaluate response. Add any other clinical facts, including the exigent circumstances behind an urgent request or information required under state and federal law, and list the attached chart notes or lab reports.
The prescriber attests that the information is true and accurate and acknowledges that the plan, insurer, medical group or its designees may audit and request records to verify it. Sign by hand or with electronic ID verification and date it. Leave the Plan/Insurer Use Only box, where the plan records receipt and decision times, approval or denial and any information requested, blank.
Download the current version from the source each time; forms change without notice.
Prescription Drug Prior Authorization or Step Therapy Exception Request Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Form 61-211 is the mandatory prescription drug prior authorization and step therapy exception form that DMHC and the Department of Insurance developed under SB 282 and AB 374 (2015), and providers use it for these requests. Plans, insurers and delegated medical groups often repost it with their own name and fax number already filled in.
72 hours for a non-urgent request and 24 hours when exigent circumstances apply. If the plan, insurer or medical group does not respond in time, the request is deemed granted. Check the Non-Urgent or Exigent Circumstances box at the top of page 1 and explain any exigency in the clinical information on page 3.
Yes. The medication section has a Step Therapy Exception Request box next to New Therapy and Renewal. For an exception, question 1 on page 3 is the key part: list each drug already tried with its dose, the dates of therapy and the response, reason for failure or allergy, and note any contraindication to the plan's preferred drug.
The instructions ask for any documentation important to the review, such as chart notes or lab data. Lab results with dates must be provided when they are needed to establish the diagnosis or evaluate response. Attachments are listed at the end of the clinical section on page 3 before the prescriber signs the attestation on page 4.