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Never paste real patient identifiers into AI tools. Remove names, dates of birth, MRNs, and insurance IDs before entering any clinical data. Use "Patient A" or similar placeholders. This is not optional — it is a HIPAA requirement.
Include the specific denial language. When appealing, paste the exact denial reason from the payer letter. AI can craft a much more targeted rebuttal when it knows the precise objection.
Name the guideline you want cited. Instead of asking for "current guidelines," specify "ADA Standards of Care 2026" or "NCCN Guidelines for Breast Cancer." This produces more accurate and verifiable references.
Always verify clinical claims before submitting. AI can generate plausible-sounding citations that do not exist. Cross-check every guideline reference and trial name against primary sources before you send the letter.
Save your best outputs as templates. When a PA letter results in a quick approval, save the prompt-and-output pair in your workflow notes. Over time, you will build a personal library of high-performing letter formats for your most common PA requests.
5 Claude Prompts for Drug Information Queries
5 Claude Prompts for MTM Documentation
Claude CoWork for Pharmacists
ClaudePharmacistBeginnerPrompt Pack
5 Claude Prompts for Prior Authorization — Pharmacists
Ready-to-use Claude prompts for writing prior authorization letters, appeal narratives, and clinical justifications that get approved faster.
Why Use AI for Prior Authorization?
Prior authorization is one of the most time-consuming tasks in pharmacy practice. Between gathering clinical documentation, writing justification letters, and navigating payer-specific requirements, a single PA can eat up 30 minutes or more of your day. Multiply that across a dozen requests per week, and you are losing hours that could be spent on direct patient care. AI tools like Claude can dramatically compress that cycle by helping you draft clear, clinically sound narratives from the data you already have.
The key advantage of using AI for PA work is consistency. Insurance reviewers scan for specific clinical criteria, and a well-structured letter that hits every required point on the first submission has a significantly higher approval rate. These prompts are designed to help you organize your clinical reasoning into the format payers expect, using language that aligns with medical necessity standards. You still bring the clinical judgment — the AI handles the writing.
That said, prior authorization documents contain protected health information, so you must de-identify all patient data before pasting it into any AI tool. Use placeholders like "Patient A" and remove dates of birth, MRNs, and other direct identifiers. The prompts below are built with bracketed placeholders to remind you where to insert de-identified information.
Prompt 1: PA Letter from Clinical Data
Draft a complete prior authorization letter from your clinical notes and lab values.
You are a clinical pharmacist writing a prior authorization letter to
[INSURANCE PLAN NAME] for [MEDICATION NAME AND STRENGTH]. The patient
has a diagnosis of [ICD-10 CODE AND DIAGNOSIS]. Write a formal PA letter
that includes: the clinical rationale for this medication, relevant lab
values ([LIST KEY LABS, e.g., A1C 9.2%, eGFR 58 mL/min]), prior
therapies tried and failed ([LIST PREVIOUS MEDICATIONS AND REASONS FOR
FAILURE]), and a clear medical necessity statement. Use professional
clinical language appropriate for a pharmacy and therapeutics reviewer.Example Output:
RE: Prior Authorization Request — Ozempic (semaglutide) 1 mg subcutaneous injection
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Dear Pharmacy Benefit Review Committee,
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I am writing to request prior authorization for Ozempic 1 mg weekly injection for Patient A, diagnosed with type 2 diabetes mellitus (E11.65) with inadequate glycemic control. Current labs reveal an A1C of 9.2% and eGFR of 58 mL/min/1.73m², indicating Stage 3a CKD, which limits available therapeutic options.
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Patient A has trialed and failed the following therapies: metformin 2000 mg daily (discontinued after 8 weeks due to persistent GI intolerance despite slow titration), and glipizide 10 mg BID (12-week trial with only 0.3% A1C reduction and two documented hypoglycemic episodes). Given the renal impairment, SGLT2 inhibitors require dose adjustment and sulfonylurea use carries elevated hypoglycemia risk.
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GLP-1 receptor agonists are recommended by ADA Standards of Care 2026 as preferred second-line therapy in patients with established CKD. Semaglutide has demonstrated both cardiovascular and renal protective benefits in the SUSTAIN and FLOW trials. This medication is medically necessary to achieve glycemic targets while preserving renal function.
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Respectfully submitted,
[Pharmacist Name, PharmD]
Why it works: Structuring the letter around tried-and-failed therapies and objective lab data mirrors the criteria most PBMs use for medical necessity review.
Prompt 2: Appeal After Initial Denial
Build a persuasive appeal narrative when the first PA submission is denied.
A prior authorization for [MEDICATION NAME] was denied by [PAYER NAME].
The denial reason was: "[PASTE DENIAL REASON, e.g., 'Step therapy
requirement not met']." Write an appeal letter that directly addresses
this denial reason. Include the following clinical facts: the patient
has tried [LIST FAILED THERAPIES WITH DATES AND OUTCOMES], has a
documented contraindication to [ALTERNATIVE DRUG] due to [REASON, e.g.,
"history of angioedema"], and current clinical guidelines from [CITE
GUIDELINE, e.g., "ADA Standards of Care 2026"] support the use of
[REQUESTED MEDICATION] in this clinical scenario. Maintain a respectful
but firm tone throughout.Example Output:
RE: Appeal of Prior Authorization Denial — Entresto (sacubitril/valsartan) 49/51 mg
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Dear Appeals Committee,
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I am writing to appeal the denial of Entresto for Patient A (Reference #PA-2026-04882). The stated denial reason was "step therapy requirement not met — trial of ACE inhibitor required." I respectfully submit that this requirement has been satisfied and that an additional trial would pose clinical risk.
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Patient A was prescribed lisinopril 20 mg daily for 14 weeks (September–December 2025) with documented persistent cough and no improvement in ejection fraction (remained at 32%). The patient was then trialed on losartan 100 mg daily for 10 weeks with inadequate response — BNP remained elevated at 840 pg/mL and the patient required one emergency department visit for acute decompensation. Enalapril is contraindicated due to a documented history of angioedema (reaction date: March 2024, confirmed in allergy records).
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ACC/AHA 2022 Heart Failure Guidelines recommend sacubitril/valsartan as a Class I recommendation for patients with HFrEF who remain symptomatic on optimized RAAS inhibitor therapy. Patient A meets this criterion. Continued delay in initiating guideline-directed therapy places the patient at risk for further cardiac deterioration.
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I respectfully request expedited review and approval of this appeal.
Prompt 3: Clinical Evidence Summary
Compile a concise evidence summary to attach as supporting documentation.
Summarize the clinical evidence supporting the use of [MEDICATION NAME]
for [INDICATION] in a 250-word evidence brief suitable for attachment to
a prior authorization submission. Include: FDA-approved indications,
key pivotal trial results (efficacy endpoints and safety profile),
relevant clinical guideline recommendations from [ORGANIZATION, e.g.,
"ACC/AHA" or "IDSA"], and where this drug fits in the current treatment
algorithm. Format the summary with clear subheadings.Example Output:
Clinical Evidence Brief: Dupixent (dupilumab) for Moderate-to-Severe Atopic Dermatitis
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FDA-Approved Indication: Dupilumab is approved for the treatment of moderate-to-severe atopic dermatitis in adults and pediatric patients aged 6 months and older whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.
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Pivotal Trial Evidence: In the SOLO 1 and SOLO 2 phase III trials (n=1,379), dupilumab 300 mg every two weeks achieved IGA 0/1 (clear or almost clear skin) in 36–38% of patients versus 8–10% with placebo at week 16 (p<0.001). EASI-75 response was reached by 44–51% of dupilumab patients versus 12–15% with placebo. The safety profile was favorable, with injection-site reactions (15%) and conjunctivitis (10%) as the most common adverse events. No increased risk of serious infection was observed compared to placebo.
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Guideline Recommendations: The AAD-NPF 2023 Guidelines for Atopic Dermatitis recommend dupilumab as a first-line systemic agent for moderate-to-severe disease in patients who are candidates for systemic therapy. It is positioned before conventional immunosuppressants (cyclosporine, methotrexate) due to its superior safety profile for long-term use.
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Place in Therapy: Dupilumab is appropriate after failure of optimized topical corticosteroids and calcineurin inhibitors, and is preferred over traditional systemics in patients requiring extended treatment duration.
Prompt 4: Step Therapy Exception Request
Request an exception when step therapy requirements do not fit the patient's clinical situation.
Write a step therapy exception request letter for [MEDICATION NAME]
prescribed to a patient with [DIAGNOSIS]. The payer requires the patient
to try [REQUIRED STEP THERAPY DRUG] first, but this is clinically
inappropriate because [REASON, e.g., "the patient has a documented
allergy to sulfonamide-derived drugs" or "the patient previously failed
this agent at another pharmacy before transferring care — pharmacy
records from [PHARMACY NAME] confirm a [X]-week trial ending [DATE]"].
Reference the payer's own exception criteria if known: [PASTE ANY
RELEVANT PLAN CRITERIA]. The letter should request an immediate override
to [REQUESTED MEDICATION] based on clinical necessity.Example Output:
RE: Step Therapy Exception Request — Eliquis (apixaban) 5 mg BID
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Dear Utilization Review Department,
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I am requesting a step therapy exception for Eliquis (apixaban) 5 mg twice daily for Patient A, diagnosed with nonvalvular atrial fibrillation (I48.91), CHA₂DS₂-VASc score of 4. The plan formulary requires an initial trial of warfarin before approving a direct oral anticoagulant. I respectfully submit that this requirement is clinically inappropriate for this patient.
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Patient A previously filled warfarin 5 mg daily at CityView Pharmacy (NPI: 1234567890) from January through March 2025. During this 10-week trial, INR monitoring revealed that the patient remained in therapeutic range (INR 2.0–3.0) only 38% of the time despite weekly dose adjustments and adherence counseling. Two INR values exceeded 4.5, and the patient experienced a clinically significant epistaxis episode requiring urgent care evaluation. The prescriber discontinued warfarin due to labile INR and high bleeding risk.
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Per your plan's own exception criteria (Section 4.2.1: "Exception may be granted when the required step therapy agent was tried and discontinued due to adverse effects or therapeutic failure"), Patient A qualifies for an immediate override. I request authorization of Eliquis 5 mg BID effective immediately to prevent thromboembolic events in this high-risk patient.
Prompt 5: Specialty Medication Justification
Build a detailed justification for high-cost specialty medications that require enhanced documentation.
Write a clinical justification for [SPECIALTY MEDICATION NAME] for a
patient with [DIAGNOSIS AND SEVERITY, e.g., "moderate-to-severe plaque
psoriasis with BSA involvement of 12%, PASI score 14"]. The patient has
failed the following conventional therapies: [LIST THERAPIES, DOSES,
DURATIONS, AND OUTCOMES]. Include objective clinical measures that
document disease severity ([LIST SCORES OR METRICS]), explain why
the requested specialty agent is the most appropriate next step per
current treatment guidelines, and note any relevant comorbidities
[LIST COMORBIDITIES] that further support this choice. Format this as
a structured clinical narrative suitable for a specialty pharmacy
benefit review.Example Output:
Clinical Justification: Skyrizi (risankizumab-rzaa) 150 mg for Moderate-to-Severe Plaque Psoriasis
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Patient A presents with moderate-to-severe chronic plaque psoriasis (L40.0) with a current BSA involvement of 12% and PASI score of 14, indicating disease that significantly impairs quality of life. DLQI score is 18 (very large effect on daily functioning). Affected areas include bilateral elbows, knees, lower back, and scalp, with plaques resistant to prior topical management.
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Failed Conventional Therapies: Patient A completed a 16-week course of methotrexate titrated to 20 mg weekly with only a 22% PASI improvement and elevated ALT (68 U/L), necessitating discontinuation. Subsequently, the patient trialed cyclosporine 4 mg/kg/day for 12 weeks, achieving partial response (PASI 40% improvement) but developing elevated serum creatinine (1.6 mg/dL), prompting discontinuation per nephrotoxicity monitoring guidelines. A 24-week trial of adalimumab (Humira) yielded initial PASI-75 response that was lost by week 20, consistent with secondary biologic failure.
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Guideline Support: AAD-NPF 2020 Joint Guidelines recommend IL-23 inhibitors as appropriate therapy following TNF-inhibitor failure. Risankizumab demonstrated PASI-90 response rates of 72–75% at week 16 in the UltIMMa-1 and UltIMMa-2 trials. Relevant comorbidities include obesity (BMI 34) and prediabetes (A1C 6.1%), both of which are associated with more severe psoriatic disease and systemic inflammation, further supporting targeted biologic therapy.