---
title: PARequest (from Prescriber – Initial Submission)
slug: electronic-prior-auth/guide/parequest-from-prescriber-initial-submission
docTags: 
createdAt: 2026-06-22T20:46:10.410Z
---

The prescriber provides the information for the follow-up question in the format indicated in the question set (by attaching a PDF document to the PARequest message).

```xml
<?xml version="1.0" encoding="utf-8"?>
<Message DatatypesVersion="20230115" TransportVersion="20230115" TransactionDomain="SCRIPT" 
TransactionVersion="20230115" StructuresVersion="20230115" ECLVersion="20230115">
  <Header>
    <To Qualifier="PY">P99999999999999</To>
    <From Qualifier="D">77777777</From>
    <MessageID>1234569</MessageID>
    <RelatesToMessageID>1234567</RelatesToMessageID>
    <SentTime>2014-07-02T14:12:14.1Z</SentTime>
    <Security>
      <Sender>
        <TertiaryIdentification>ACCT_ID_INSERTED_BY_SS</TertiaryIdentification>
      </Sender>
      <Receiver>
        <TertiaryIdentification>ACCT_ID_INSERTED_BY_SS</TertiaryIdentification>
      </Receiver>
    </Security>
    <SenderSoftware>
      <SenderSoftwareDeveloper>MDLITE</SenderSoftwareDeveloper>
      <SenderSoftwareProduct>443</SenderSoftwareProduct>
      <SenderSoftwareVersionRelease>2.1</SenderSoftwareVersionRelease>
    </SenderSoftware>
  </Header>
  <Body>
    <PARequest>
      <PAReferenceID>77XX2</PAReferenceID>
      <BenefitsCoordination>
        <PBMMemberID>333445555</PBMMemberID>
      </BenefitsCoordination>
      <Patient>
        <HumanPatient>
          <Names>
            <Name xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
              <LastName>SMITH</LastName>
              <FirstName>MARY</FirstName>
            </Name>
          </Names>
          <GenderAndSex>
            <AdministrativeGender>F</AdministrativeGender>
          </GenderAndSex>
          <DateOfBirth>
            <Date>1954-12-25</Date>
          </DateOfBirth>
          <Address>
            <AddressLine1>45 EAST ROAD SW</AddressLine1>
            <City>CLANCY</City>
            <StateProvince>WI</StateProvince>
            <PostalCode>54999</PostalCode>
            <CountryCode>US</CountryCode>
          </Address>
        </HumanPatient>
      </Patient>
      <Pharmacy>
        <Identification>
          <NCPDPID>7701630</NCPDPID>
          <NPI>7878787878</NPI>
        </Identification>
        <BusinessName>MAIN STREET PHARMACY</BusinessName>
        <CommunicationNumbers>
          <PrimaryTelephone>
            <Number>6155555656</Number>
          </PrimaryTelephone>
        </CommunicationNumbers>
      </Pharmacy>
      <Prescriber>
        <NonVeterinarian>
          <Identification>
            <NPI>666666666</NPI>
          </Identification>
          <Names>
            <Name xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
              <LastName>JONES</LastName>
              <FirstName>MARK</FirstName>
            </Name>
          </Names>
          <Address>
            <AddressLine1>211 CENTRAL ROAD</AddressLine1>
            <City>JONESVILLE</City>
            <StateProvince>TN</StateProvince>
            <PostalCode>37777</PostalCode>
            <CountryCode>US</CountryCode>
          </Address>
          <CommunicationNumbers>
            <PrimaryTelephone>
              <Number>6152219800</Number>
            </PrimaryTelephone>
          </CommunicationNumbers>
        </NonVeterinarian>
      </Prescriber>
      <MedicationPrescribed>
        <DrugDescription xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">LOVENOX 40 MG PER 0.4 ML PREFILLED SYRINGE</DrugDescription>
        <Product>
          <NonDrugCoded>
            <Strength>
              <StrengthValue>100</StrengthValue>
              <StrengthForm>
                <Code>C42945</Code>
              </StrengthForm>
              <StrengthUnitOfMeasure>
                <Code>C42576</Code>
              </StrengthUnitOfMeasure>
            </Strength>
          </NonDrugCoded>
        </Product>
        <Quantity>
          <Value>30</Value>
          <CodeListQualifier>38</CodeListQualifier>
          <QuantityUnitOfMeasure>
            <Code>C48540</Code>
          </QuantityUnitOfMeasure>
        </Quantity>
        <DaysSupply>30</DaysSupply>
        <Diagnosis>
          <ClinicalInformationQualifier>1</ClinicalInformationQualifier>
          <Qualifier>ABF</Qualifier>
          <Value>E11.9</Value>
          <Description>DIABETES MELLITUS</Description>
        </Diagnosis>
        <Sig>
          <SigText>INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY</SigText>
        </Sig>
      </MedicationPrescribed>
      <Attachment>
        <AttachmentSource>Patient Medical Record</AttachmentSource>
        <AttachmentData />
        <CDA>
          <TemplateID>2.16.840.1.113883.10.20.22.1.2</TemplateID>
        </CDA>
        <MIMEType>application/hl7-sda+xml</MIMEType>
      </Attachment>
      <Request>
        <SolicitedModel>
          <PACaseID>A101</PACaseID>
          <DeadlineForReply>
            <DateTime>2014-10-01T23:59:59</DateTime>
          </DeadlineForReply>
          <QuestionSet>
            <Header>
              <QuestionSetID>QS101</QuestionSetID>
              <QuestionSetTitle>Lovenox PA Form</QuestionSetTitle>
              <QuestionSetDescription>Please provide all information requested. Failure to complete this form in its entirety may result in delayed processing or an adverse determination for insufficient information.</QuestionSetDescription>
              <QuestionSetContactCommunicationNumber>
                <PrimaryTelephone>
                  <Number>5555551212</Number>
                </PrimaryTelephone>
              </QuestionSetContactCommunicationNumber>
              <AttachmentRequired>false</AttachmentRequired>
            </Header>
            <Question>
              <QuestionID>Q1</QuestionID>
              <SequenceNumber>1</SequenceNumber>
              <QuestionText>Is this patient home self-administering?</QuestionText>
              <DefaultNextQuestionID>Q2</DefaultNextQuestionID>
              <QuestionType>
                <Select>
                  <SelectMultiple>false</SelectMultiple>
                  <Choice>
                    <ChoiceID>Q1C1</ChoiceID>
                    <SequenceNumber>1</SequenceNumber>
                    <ChoiceText>Yes</ChoiceText>
                    <AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
                  </Choice>
                  <Choice>
                    <ChoiceID>Q1C2</ChoiceID>
                    <SequenceNumber>2</SequenceNumber>
                    <ChoiceText>No</ChoiceText>
                    <AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
                  </Choice>
                  <Answer>
                    <SubmitterProvidedAnswer>
                      <ChoiceID xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Q1C1</ChoiceID>
                    </SubmitterProvidedAnswer>
                  </Answer>
                </Select>
              </QuestionType>
            </Question>
            <Question>
              <QuestionID>Q2</QuestionID>
              <SequenceNumber>2</SequenceNumber>
              <QuestionText>Is the medication to be used to treat prophylaxis?</QuestionText>
              <QuestionType>
                <Select>
                  <SelectMultiple>false</SelectMultiple>
                  <Choice>
                    <ChoiceID>Q2C1</ChoiceID>
                    <SequenceNumber>1</SequenceNumber>
                    <ChoiceText>Yes</ChoiceText>
                    <AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
                    <NextQuestionID>Q3</NextQuestionID>
                  </Choice>
                  <Choice>
                    <ChoiceID>Q2C2</ChoiceID>
                    <SequenceNumber>2</SequenceNumber>
                    <ChoiceText>No</ChoiceText>
                    <AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
                    <NextQuestionID>Q4</NextQuestionID>
                  </Choice>
                  <Answer>
                    <SubmitterProvidedAnswer>
                      <ChoiceID xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Q2C2</ChoiceID>
                    </SubmitterProvidedAnswer>
                  </Answer>
                </Select>
              </QuestionType>
            </Question>
            <Question>
              <QuestionID>Q3</QuestionID>
              <SequenceNumber>3</SequenceNumber>
              <QuestionText>When was or will the surgery be done?</QuestionText>
              <DefaultNextQuestionID>Q6</DefaultNextQuestionID>
              <QuestionType>
                <Date>
                  <IsDateTimeRequired>false</IsDateTimeRequired>
                </Date>
              </QuestionType>
            </Question>
            <Question>
              <QuestionID>Q4</QuestionID>
              <SequenceNumber>4</SequenceNumber>
              <QuestionText>Is the medication to be used for treatment of DVT?</QuestionText>
              <QuestionType>
                <Select>
                  <SelectMultiple>false</SelectMultiple>
                  <Choice>
                    <ChoiceID>Q4C1</ChoiceID>
                    <SequenceNumber>1</SequenceNumber>
                    <ChoiceText>Yes</ChoiceText>
                    <AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
                    <NextQuestionID>Q5</NextQuestionID>
                  </Choice>
                  <Choice>
                    <ChoiceID>Q4C2</ChoiceID>
                    <SequenceNumber>2</SequenceNumber>
                    <ChoiceText>No</ChoiceText>
                    <AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
                    <NextQuestionID>Q6</NextQuestionID>
                  </Choice>
                  <Answer>
                    <SubmitterProvidedAnswer>
                      <ChoiceID xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Q4C1</ChoiceID>
                    </SubmitterProvidedAnswer>
                  </Answer>
                </Select>
              </QuestionType>
            </Question>
            <Question>
              <QuestionID>Q5</QuestionID>
              <SequenceNumber>5</SequenceNumber>
              <QuestionText>What is the patient's weight (in pounds)?</QuestionText>
              <DefaultNextQuestionID>Q6</DefaultNextQuestionID>
              <QuestionType>
                <Numeric>
                  <IsNumeric>true</IsNumeric>
                  <Answer>
                    <SubmitterProvidedNumericAnswer>164</SubmitterProvidedNumericAnswer>
                  </Answer>
                </Numeric>
              </QuestionType>
            </Question>
            <Question>
              <QuestionID>Q6</QuestionID>
              <SequenceNumber>6</SequenceNumber>
              <QuestionText>Describe result of Warfarin use (include INR and date drawn) or reason why patient can't use Warfarin. You may attach supporting information in a PDF document.</QuestionText>
              <DefaultNextQuestionID>END</DefaultNextQuestionID>
              <QuestionType>
                <FreeText>
                  <IsFreeText>true</IsFreeText>
                  <Answer>
                    <SubmitterProvidedAnswer>Patient tried Warfarin without success. See attached CCD with treatment history.</SubmitterProvidedAnswer>
                  </Answer>
                </FreeText>
              </QuestionType>
            </Question>
          </QuestionSet>
        </SolicitedModel>
      </Request>
    </PARequest>
  </Body>
</Message>
```

**PARequest (from Prescriber) Example Element Details**

:::hint{type="info"}
**Note:&#x20;**&#x54;he table below does not explain every element displayed in the XML example.
:::

| **Element**                                                                                             | **Value**                                                                                                                                                                          | ****                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
| ------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| To                                                                                                      | P99999999999999\:PY                                                                                                                                                                | ID of the receiving PBM/payer; PY means it is the payer.                                                                                                                                                                                                                                                                                                                                                                                                |
| From                                                                                                    | 77777777\:D                                                                                                                                                                        | SPI assigned to the prescriber; D is the qualifier for a Prescriber ID.                                                                                                                                                                                                                                                                                                                                                                                 |
| MessageID                                                                                               | 1234569                                                                                                                                                                            | Initiating system trace number for the transmission. Echoed back in the response message in RelatesToMessageID.                                                                                                                                                                                                                                                                                                                                         |
| RelatesToMessageID                                                                                      | 1234567                                                                                                                                                                            | Used to link the most recent message received from a trading partner in the conversation to this subsequent message.                                                                                                                                                                                                                                                                                                                                    |
| SentTime                                                                                                | 2014-07-02T14🕛14.1Z                                                                                                                                                               | Date and time message was sent: 07/02/2014 14🕛14.1 PM                                                                                                                                                                                                                                                                                                                                                                                                  |
| PARequest                                                                                               | PARequest                                                                                                                                                                          | Message type.                                                                                                                                                                                                                                                                                                                                                                                                                                           |
| SenderSoftwareDeveloper, SenderSoftwareProduct, SenderSoftwareVersionRelease                            | MDLITE:443:2.1                                                                                                                                                                     | Sender Software Developer: MDLITE<br />Sender Software Product: 443<br />Sender Software Version Release: 2.1                                                                                                                                                                                                                                                                                                                                           |
| PrescriberOrderNumber                                                                                   |                                                                                                                                                                                    | Not sent. Not applicable.                                                                                                                                                                                                                                                                                                                                                                                                                               |
| RxReferenceNumber                                                                                       |                                                                                                                                                                                    | Not sent. Not applicable.                                                                                                                                                                                                                                                                                                                                                                                                                               |
| PAReferenceID                                                                                           | 77XX2                                                                                                                                                                              | Assigned by the prescribing system on the initial message and is used as a tracking identifier on all request and response prior authorization messages to tieback related prior authorization messages. The identifier must be unique per prescribing system for at least 18 months.<br />**Note:** PAReferenceID shall be established with the PARequest when responding to a Prior Authorization renewal request (unsolicited PAInitiationResponse). |
| PBMMemberID                                                                                             | 333445555                                                                                                                                                                          | PBM/payer-assigned member ID for the patient.                                                                                                                                                                                                                                                                                                                                                                                                           |
| SocialSecurity                                                                                          | 333445555                                                                                                                                                                          | Patient’s Social Security Number.                                                                                                                                                                                                                                                                                                                                                                                                                       |
| LastName, FirstName                                                                                     | SMITH\:MARY                                                                                                                                                                        | Patient’s name.                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| Gender                                                                                                  | F                                                                                                                                                                                  | Patient's gender.                                                                                                                                                                                                                                                                                                                                                                                                                                       |
| DateOfBirth                                                                                             | 1954-12-25                                                                                                                                                                         | Patient’s date of birth.                                                                                                                                                                                                                                                                                                                                                                                                                                |
| Address                                                                                                 | 45 EAST ROAD SW, CLANCY, WI, 54999                                                                                                                                                 | Patient’s address.                                                                                                                                                                                                                                                                                                                                                                                                                                      |
| NCPDPID                                                                                                 | 7701630                                                                                                                                                                            | NCPDP Provider ID Number of Pharmacy.                                                                                                                                                                                                                                                                                                                                                                                                                   |
| NPI                                                                                                     | 7878787878                                                                                                                                                                         | National Provider ID of Pharmacy.                                                                                                                                                                                                                                                                                                                                                                                                                       |
| StoreName                                                                                               | MAIN STR...                                                                                                                                                                        | Name of Pharmacy.                                                                                                                                                                                                                                                                                                                                                                                                                                       |
| CommunicationNumber                                                                                     | 6155555656                                                                                                                                                                         | Phone Number of Pharmacy.                                                                                                                                                                                                                                                                                                                                                                                                                               |
| NPI                                                                                                     | 666666666                                                                                                                                                                          | NPI of the Prescriber.                                                                                                                                                                                                                                                                                                                                                                                                                                  |
| LastName, FirstName                                                                                     | JONES\:MARK                                                                                                                                                                        | Prescriber’s name.                                                                                                                                                                                                                                                                                                                                                                                                                                      |
| Address                                                                                                 | 211 CENTRAL ROAD, JONESVILLE, TN, 37777                                                                                                                                            | Prescriber’s address.                                                                                                                                                                                                                                                                                                                                                                                                                                   |
| CommunicationNumber                                                                                     | 6155559800                                                                                                                                                                         | Prescriber’s phone number.                                                                                                                                                                                                                                                                                                                                                                                                                              |
| DrugDescription                                                                                         | LOVENOX 40 MG PER 0.4 ML PREFILLED SYRINGE                                                                                                                                         | Drug prescribed is Lovenox 40 MG per 0.4 ML Prefilled Syringe.                                                                                                                                                                                                                                                                                                                                                                                          |
| Strength                                                                                                | 100                                                                                                                                                                                | 100 is the strength.                                                                                                                                                                                                                                                                                                                                                                                                                                    |
| StrengthForm                                                                                            | C42945                                                                                                                                                                             | C42945 is the code for "injectable solution".                                                                                                                                                                                                                                                                                                                                                                                                           |
| StrengthUnitOfMeasure                                                                                   | C42576                                                                                                                                                                             | C42576 is the code for "milligrams per milliliter".                                                                                                                                                                                                                                                                                                                                                                                                     |
| Quantity                                                                                                | 30:38                                                                                                                                                                              | Quantity is 30. 38 is the code value for Original Qty.                                                                                                                                                                                                                                                                                                                                                                                                  |
| QuantityUnitOfMeasure                                                                                   | C48540                                                                                                                                                                             | C48540 is the code for "Syringe".                                                                                                                                                                                                                                                                                                                                                                                                                       |
| DaysSupply                                                                                              | 30                                                                                                                                                                                 | 30 is the number of days supply.                                                                                                                                                                                                                                                                                                                                                                                                                        |
| Diagnosis Code                                                                                          | E11.9                                                                                                                                                                              | E11.9 is the diagnosis code for Diabetes mellitus.                                                                                                                                                                                                                                                                                                                                                                                                      |
| SigText                                                                                                 | INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY                                                                                                                                             | INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY... is the Sig.                                                                                                                                                                                                                                                                                                                                                                                                   |
| **Attachment**                                                                                          |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| AttachmentSource                                                                                        | Patient medical record                                                                                                                                                             | Indicates that the information was retrieved from the patient’s medical record.                                                                                                                                                                                                                                                                                                                                                                         |
| AttachmentData                                                                                          | Base64-encoded CCD document                                                                                                                                                        | Attached CCD document (BASE64 encoded).                                                                                                                                                                                                                                                                                                                                                                                                                 |
| CDA\:TemplateID                                                                                         | 2.16.840.1.113883.10.20.22.1.2                                                                                                                                                     | CDA TemplateID for the Continuity of Care Document (CCD).                                                                                                                                                                                                                                                                                                                                                                                               |
| MIMEType                                                                                                | application/hl7-sda+xml                                                                                                                                                            | MIME type for CDA documents.                                                                                                                                                                                                                                                                                                                                                                                                                            |
| **Request**                                                                                             |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| SolicitedModel                                                                                          | SolicitedModel                                                                                                                                                                     |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| PACaseID                                                                                                | A101                                                                                                                                                                               | PBM/payer-assigned identifier for this request.                                                                                                                                                                                                                                                                                                                                                                                                         |
| DeadlineForReply                                                                                        | 2014-10-01T23:59:59                                                                                                                                                                | Deadline for response (echoed from PAInitiationResponse).                                                                                                                                                                                                                                                                                                                                                                                               |
| **QuestionSet**                                                                                         |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| QuestionSet                                                                                             |                                                                                                                                                                                    | A question set is included in the PBM/payer’s response.                                                                                                                                                                                                                                                                                                                                                                                                 |
| Header                                                                                                  |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| QuestionSetID                                                                                           | QS101                                                                                                                                                                              | PBM/payer-assigned ID for this question set.                                                                                                                                                                                                                                                                                                                                                                                                            |
| QuestionSetTitle                                                                                        | Lovenox PA Form                                                                                                                                                                    | Title of the question set, "Lovenox PA Form" can be presented to the end-user.                                                                                                                                                                                                                                                                                                                                                                          |
| QuestionSetDescription                                                                                  | Please provide all information requested. Failure to complete this form in its entirety may result in delayed processing or an adverse determination for insufficient information. | Instructions for the end-user.                                                                                                                                                                                                                                                                                                                                                                                                                          |
| QuestionSetContactPhoneNumber                                                                           | 5555551212                                                                                                                                                                         | Contact phone number at the PBM/payer for questions related to this PA process.                                                                                                                                                                                                                                                                                                                                                                         |
| AttachementRequired                                                                                     | N                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| **Question 1**                                                                                          |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| Question                                                                                                |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| QuestionID                                                                                              | Q1                                                                                                                                                                                 | PBM/payer-assigned ID for this question.                                                                                                                                                                                                                                                                                                                                                                                                                |
| QuestionText                                                                                            | Is this patient home self-administering?                                                                                                                                           | Question text to be displayed to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                          |
| SequenceNumber                                                                                          | 1                                                                                                                                                                                  | Order of this question relative to other questions in this question set.                                                                                                                                                                                                                                                                                                                                                                                |
| DefaultNextQuestionID                                                                                   | Q2                                                                                                                                                                                 | Next question to display regardless of the answer to this question.                                                                                                                                                                                                                                                                                                                                                                                     |
| Select                                                                                                  |                                                                                                                                                                                    | Type of this question is Select.                                                                                                                                                                                                                                                                                                                                                                                                                        |
| SelectMultiple                                                                                          | N                                                                                                                                                                                  | Only one answer may be returned for this question. (No)                                                                                                                                                                                                                                                                                                                                                                                                 |
| **Choice - First choice**                                                                               |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| ChoiceID                                                                                                | Q1C1                                                                                                                                                                               | PBM/payer-assigned ID for this choice.                                                                                                                                                                                                                                                                                                                                                                                                                  |
| ChoiceText                                                                                              | Yes                                                                                                                                                                                | Text to be presented to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                                   |
| SequenceNumber                                                                                          | 1                                                                                                                                                                                  | Order of this choice relative to other choices for this question.                                                                                                                                                                                                                                                                                                                                                                                       |
| AdditionalFreeTextIndicator                                                                             | NA                                                                                                                                                                                 | No additional free text is allowed when selecting this choice.                                                                                                                                                                                                                                                                                                                                                                                          |
| **Choice - Second choice**                                                                              |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| ChoiceID                                                                                                | Q1C2                                                                                                                                                                               | PBM/payer-assigned ID for this choice.                                                                                                                                                                                                                                                                                                                                                                                                                  |
| ChoiceText                                                                                              | No                                                                                                                                                                                 | Text to be presented to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                                   |
| SequenceNumber                                                                                          | 2                                                                                                                                                                                  | Order of this choice relative to other choices for this question.                                                                                                                                                                                                                                                                                                                                                                                       |
| AdditionalFreeTextIndicator                                                                             | NA                                                                                                                                                                                 | No additional free text is allowed when selecting this choice.                                                                                                                                                                                                                                                                                                                                                                                          |
| Answer                                                                                                  |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| PrescriberProvidedAnswer                                                                                |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| ChoiceID                                                                                                | Q1C1                                                                                                                                                                               | ChoiceID associated with the selected choice.                                                                                                                                                                                                                                                                                                                                                                                                           |
| **Question 2**                                                                                          |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| Question                                                                                                |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| QuestionID                                                                                              | Q2                                                                                                                                                                                 | PBM/payer-assigned ID for this question.                                                                                                                                                                                                                                                                                                                                                                                                                |
| QuestionText                                                                                            | Is the medication to be used to treat prophylaxis?                                                                                                                                 | Question text to be displayed to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                          |
| SequenceNumber                                                                                          | 2                                                                                                                                                                                  | Order of this question relative to other questions in this question set.                                                                                                                                                                                                                                                                                                                                                                                |
| Select                                                                                                  |                                                                                                                                                                                    | Type of this question is Select.                                                                                                                                                                                                                                                                                                                                                                                                                        |
| SelectMultiple                                                                                          | N                                                                                                                                                                                  | Only one answer may be returned for this question. (No)                                                                                                                                                                                                                                                                                                                                                                                                 |
| Choice                                                                                                  |                                                                                                                                                                                    | First choice                                                                                                                                                                                                                                                                                                                                                                                                                                            |
| ChoiceID                                                                                                | Q2C1                                                                                                                                                                               | PBM/payer-assigned ID for this choice.                                                                                                                                                                                                                                                                                                                                                                                                                  |
| ChoiceText                                                                                              | Yes                                                                                                                                                                                | Text to be presented to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                                   |
| SequenceNumber                                                                                          | 1                                                                                                                                                                                  | Order of this choice relative to other choices for this question.                                                                                                                                                                                                                                                                                                                                                                                       |
| NextQuestionID                                                                                          | Q3                                                                                                                                                                                 | Next question to be answered if this choice is selected.                                                                                                                                                                                                                                                                                                                                                                                                |
| AdditionalFreeTextIndicator                                                                             | NA                                                                                                                                                                                 | No additional free text is allowed when selecting this choice.                                                                                                                                                                                                                                                                                                                                                                                          |
| Choice                                                                                                  |                                                                                                                                                                                    | Second choice                                                                                                                                                                                                                                                                                                                                                                                                                                           |
| ChoiceID                                                                                                | Q2C2                                                                                                                                                                               | PBM/payer-assigned ID for this choice.                                                                                                                                                                                                                                                                                                                                                                                                                  |
| ChoiceText                                                                                              | No                                                                                                                                                                                 | Text to be presented to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                                   |
| SequenceNumber                                                                                          | 2                                                                                                                                                                                  | Order of this choice relative to other choices for this question.                                                                                                                                                                                                                                                                                                                                                                                       |
| NextQuestionID                                                                                          | Q4                                                                                                                                                                                 | Next question to be answered if this choice is selected.                                                                                                                                                                                                                                                                                                                                                                                                |
| AdditionalFreeTextIndicator                                                                             | NA                                                                                                                                                                                 | No additional free text is allowed when selecting this choice.                                                                                                                                                                                                                                                                                                                                                                                          |
| Answer                                                                                                  |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| PrescriberProvidedAnswer                                                                                |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| ChoiceID                                                                                                | Q2C2                                                                                                                                                                               | ChoiceID associated with the selected choice.                                                                                                                                                                                                                                                                                                                                                                                                           |
| **Question 3 - Conditional question to be asked if Question 2 answer is Yes**                           |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| Question                                                                                                |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| QuestionID                                                                                              | Q3                                                                                                                                                                                 | PBM/payer-assigned ID for this question.                                                                                                                                                                                                                                                                                                                                                                                                                |
| QuestionText                                                                                            | When was or will the surgery be done?                                                                                                                                              | Question text to be displayed to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                          |
| SequenceNumber                                                                                          | 3                                                                                                                                                                                  | Order of this question relative to other questions in this question set.                                                                                                                                                                                                                                                                                                                                                                                |
| DefaultNextQuestionID                                                                                   | Q6                                                                                                                                                                                 | Next question to display regardless of the answer to this question.                                                                                                                                                                                                                                                                                                                                                                                     |
| Date                                                                                                    |                                                                                                                                                                                    | Type of this question is Date.                                                                                                                                                                                                                                                                                                                                                                                                                          |
| IsDateTimeRequired                                                                                      | N                                                                                                                                                                                  | Time information is not required in the response to this question. (No)                                                                                                                                                                                                                                                                                                                                                                                 |
| **Note:** This question was not answered based on the NextQuestionID of the previously selected answer. |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| **Question 4**                                                                                          |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| Question                                                                                                |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| QuestionID                                                                                              | Q4                                                                                                                                                                                 | PBM/payer-assigned ID for this question.                                                                                                                                                                                                                                                                                                                                                                                                                |
| QuestionText                                                                                            | Is the medication to be used for treatment of DVT?                                                                                                                                 | Question text to be displayed to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                          |
| SequenceNumber                                                                                          | 4                                                                                                                                                                                  | Order of this question relative to other questions in this question set.                                                                                                                                                                                                                                                                                                                                                                                |
| Select                                                                                                  |                                                                                                                                                                                    | Type of this question is Select.                                                                                                                                                                                                                                                                                                                                                                                                                        |
| SelectMultiple                                                                                          | N                                                                                                                                                                                  | Only one answer may be returned for this question. (No)                                                                                                                                                                                                                                                                                                                                                                                                 |
| **Choice - First choice**                                                                               |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| ChoiceID                                                                                                | Q4C1                                                                                                                                                                               | PBM/payer-assigned ID for this choice.                                                                                                                                                                                                                                                                                                                                                                                                                  |
| ChoiceText                                                                                              | Yes                                                                                                                                                                                | Text to be presented to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                                   |
| SequenceNumber                                                                                          | 1                                                                                                                                                                                  | Order of this choice relative to other choices for this question.                                                                                                                                                                                                                                                                                                                                                                                       |
| NextQuestionID                                                                                          | Q5                                                                                                                                                                                 | Next question to be answered if this choice is selected.                                                                                                                                                                                                                                                                                                                                                                                                |
| AdditionalFreeTextIndicator                                                                             | NA                                                                                                                                                                                 | No additional free text is allowed when selecting this choice.                                                                                                                                                                                                                                                                                                                                                                                          |
| **Choice - Second choice**                                                                              |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| ChoiceID                                                                                                | Q4C2                                                                                                                                                                               | PBM/payer-assigned ID for this choice.                                                                                                                                                                                                                                                                                                                                                                                                                  |
| ChoiceText                                                                                              | No                                                                                                                                                                                 | Text to be presented to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                                   |
| SequenceNumber                                                                                          | 2                                                                                                                                                                                  | Order of this choice relative to other choices for this question.                                                                                                                                                                                                                                                                                                                                                                                       |
| NextQuestionID                                                                                          | Q6                                                                                                                                                                                 | Next question to be answered if this choice is selected.                                                                                                                                                                                                                                                                                                                                                                                                |
| AdditionalFreeTextIndicator                                                                             | NA                                                                                                                                                                                 | No additional free text is allowed when selecting this choice.                                                                                                                                                                                                                                                                                                                                                                                          |
| Answer                                                                                                  |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| PrescriberProvidedAnswer                                                                                |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| ChoiceID                                                                                                | Q4C1                                                                                                                                                                               | ChoiceID associated with the selected choice.                                                                                                                                                                                                                                                                                                                                                                                                           |
| **Question 5 - Conditional question to be asked if previous question’s answer is Yes**                  |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| Question                                                                                                |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| QuestionID                                                                                              | Q5                                                                                                                                                                                 | PBM/payer-assigned ID for this question.                                                                                                                                                                                                                                                                                                                                                                                                                |
| QuestionText                                                                                            | What is the patient’s current weight (in pounds)?                                                                                                                                  | Question text to be displayed to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                          |
| DefaultNextQuestionID                                                                                   | Q6                                                                                                                                                                                 | Next question to display regardless of the answer to this question.                                                                                                                                                                                                                                                                                                                                                                                     |
| SequenceNumber                                                                                          | 5                                                                                                                                                                                  | Order of this question relative to other questions in this question set.                                                                                                                                                                                                                                                                                                                                                                                |
| IsNumeric                                                                                               |                                                                                                                                                                                    | Type of this question is Numeric.                                                                                                                                                                                                                                                                                                                                                                                                                       |
| Answer                                                                                                  |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| PrescriberProvidedAnswer                                                                                | 164                                                                                                                                                                                |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| **Question 6**                                                                                          |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| Question                                                                                                |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| QuestionID                                                                                              | Q6                                                                                                                                                                                 | PBM/payer-assigned ID for this question.                                                                                                                                                                                                                                                                                                                                                                                                                |
| QuestionText                                                                                            | Describe result of Warfarin use (include INR and date drawn) or reason why patient can't use Warfarin. You may attach supporting information in a PDF document.                    | Question text to be displayed to the end-user.                                                                                                                                                                                                                                                                                                                                                                                                          |
| DefaultNextQuestionID                                                                                   | END                                                                                                                                                                                | Last question in the question set.                                                                                                                                                                                                                                                                                                                                                                                                                      |
| SequenceNumber                                                                                          | 6                                                                                                                                                                                  | Order of this question relative to other questions in this question set.                                                                                                                                                                                                                                                                                                                                                                                |
| IsFreeText                                                                                              | Y                                                                                                                                                                                  | Indicates this is a free text question. (Yes)                                                                                                                                                                                                                                                                                                                                                                                                           |
| **Answer**                                                                                              |                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| PrescriberProvidedAnswer                                                                                | Patient tried Warfarin without success. See attached CCD with treatment history.                                                                                                   |                                                                                                                                                                                                                                                                                                                                                                                                                                                         |