CurrentAetnaPolicy N/A

Request for Medicare Prescription Drug Coverage Determination (SilverScript form)

This document is a SilverScript/SilverScript Insurance Company form for enrollees, prescribers, or authorized representatives to request Medicare Part D prescription drug coverage determinations, exceptions, prior authorizations, expedited reviews, appeals, and related supporting information.

Policy Summary

PayerAetna

PolicyRequest for Medicare Prescription Drug Coverage Determination (SilverScript form)

Policy CodePolicy N/A

Change TypeAdministrative — form/reference document

Effective DateN/A

Next Review DateN/A

Key ActionUse this form to request formulary exceptions, prior authorizations, tiering or quantity limit exceptions, reimbursement for paid prescriptions, or expedited reviews and include prescriber supporting information when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24/7phone availability for coverage determination requests

1-855-633-7673fax number to send form

1-866-235-5660phone number for coverage determinations

24hexpedited decision timeframe when prescriber supports harm

72h

Coverage Determination Requirements

Coverage determination criteria

Covered when the form is completed with required enrollee/prescriber identification, clinical justification, and signature; formulary or tiering exceptions require a prescriber supporting statement and prior authorization requests may require additional documentation.

ALL of the following

Requestor may be
- Enrollee (member) submitting the form
- Prescriber submitting the form
- Authorized representative submitting the form; representative must provide documentation (e.g., CMS-1696) to demonstrate authority

ALL of the following

Diagnosis and medical information: list all diagnoses treated with the requested drug and corresponding ICD-10 code(s), plus other relevant diagnoses
Medication details: medication name, strength/route, frequency, date started (indicate new start if applicable), expected length of therapy, quantity per 30 days, height/weight, drug allergies
Drug history: prior drugs tried for the condition, dates of trials, results (failure vs intolerance), unit/total daily dose if quantity-limit issue, and current drug regimen

ALL of the following

Prescriber must provide when applicable
- Prescriber statement is required for formulary and tiering exception requests
- Prior authorization requests may require supporting information (prescriber may use attached 'Supporting Information for an Exception Request or Prior Authorization' form)
Rationale options (select as applicable)
- Alternate drugs contraindicated or previously tried with adverse outcome — specify drugs tried, results, adverse outcomes, maximum dose and length of therapy for therapeutic failures, or reasons for contraindications
- Patient stable on current drug(s) with high risk of significant adverse clinical outcome if medication changed — provide specific explanation of anticipated adverse outcomes

ALL of the following

Requester may check 'Request for expedited review' and sign to certify that applying the standard 72-hour timeframe may seriously jeopardize the enrollee's life, health, or ability to regain maximum function
If prescriber indicates expedited need, plan will apply the expedited (24-hour) decision timeframe as appropriate

ALL of the following

Form must include enrollee and prescriber identification and contact information
Prescriber signature or authorized signatory and date as required
Attach any supporting documents relevant to the request (clinical records, test results, prior drug trial documentation)

Diagnosis and Medication Coding

Diagnosis codingICD-10

ICD-10

Diagnosis codes requested for indication

Opioid MED

MetricDaily cumulative Morphine Equivalent Dose (MED) in mg/day may be requested for opioid requests

Required detailsForm asks for the numeric MED value (mg/day) and whether other opioid prescribers are involved

Clinical justificationForm asks whether the stated daily MED is medically necessary and whether a lower total daily MED would be insufficient to control the enrollee's pain

Follow-up promptsIf other opioid prescribers exist, the form requests explanation

What Providers / Prescribers Must Do

Prior Authorization

Types of Coverage Determination Requests

Types of coverage determination requests — formulary exceptions, prior authorizations, tiering exceptions, quantity limit exceptions, reimbursement requests. If you are asking for a formulary or tiering exception, your prescriber MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement) may require supporting information. Your prescriber may use the enclosed 'Supporting Information for an Exception Request or Prior Authorization' form to support your request.

Formulary exception for a drug not on the plan's formulary
Formulary exception for a drug removed from the formulary during the plan year
Prior authorization request for a prescribed drug
Exception to step-therapy (requirement to try another drug before the prescribed drug)
Exception to a quantity limit to receive the prescribed number of pills
Tiering exception to pay a lower copayment when clinically appropriate
Tiering exception when a drug is moved to a higher copayment tier
Request for reimbursement for a covered drug paid out-of-pocket

Key Definitions

Representative

DefinitionAn individual authorized to act on behalf of the enrollee

Documentation requirementRepresentative must provide documentation (e.g., CMS-1696) to demonstrate authority

Who may make a requestPrescriber may ask for a coverage determination on the enrollee's behalf; representatives may also request if properly designated

Expedited decision

DefinitionAn expedited (fast) decision is requested when waiting 72 hours for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function

Prescriber-supported timeframeIf the prescriber indicates waiting 72 hours could seriously harm the enrollee, the plan will provide a decision within 24 hours

Documentation Required

Supporting Information and Expedited Review

FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber's supporting statement. PRIOR AUTHORIZATION requests may require supporting information. Use the 'Supporting Information for an Exception Request or Prior Authorization' form when submitting clinical rationale, relevant medical records, prior treatment history, and any other documentation that supports medical necessity. If the enrollee or prescriber believes that waiting for the standard review timeframe would seriously jeopardize life, health, or the enrollee's ability to regain maximum function, check the box to request an expedited review. Expedited (72-hour) review is available when the prescriber's statement or other documentation indicates that delay would pose serious harm.

Prescriber supporting statement is required for formulary and tiering exceptions
Provide clinical rationale, relevant medical records, prior treatment history, and documentation of why exceptions or authorization are medically necessary
Include completed Authorization of Representation (CMS-1696) or equivalent if someone other than the enrollee or prescriber files an appeal or request on the enrollee's behalf
To request expedited review, the prescriber or enrollee must certify that the standard timeframe may seriously jeopardize life, health, or ability to regain maximum function