Enter Study Data

Date Prior Authorization (PA) Submitted *

Date PA Approved *

Date First Fill Completed

Was Appeal Needed? *

Date of Appeal Submission 1

Date of Appeal Submission 2

Optional second appeal round

Date of Appeal Submission 3

Optional third appeal round

Date Appeal Resolved *

Final PA Approval Outcome *

Time Rx to PA Submission (days) (Auto-calculated)

Auto-calculated: Date PA Submitted - Date of Prescription

Time PA Submission to Approval (days) (Auto-calculated)

Auto-calculated: Date PA Approved - Date PA Submitted

Time PA to First Fill (days) (Auto-calculated)

Auto-calculated: Date First Fill - Date PA Approved

Total Time: Rx to First Fill (days) (Auto-calculated)

Auto-calculated: Date First Fill - Date of Prescription

Who Submitted PA *

Who Followed Up

Free text / initials

Barrier to prior auth approval *

Insurance delay

Missing info

Step therapy required

Lab needed

EMR error

Other (please specify)

Notes on Delay

Patient Received Medication?

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