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Request for Medicare Prescription Drug Coverage Determination (SilverScript form)
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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.
No material clinical or coverage changes in this revision.
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
- Medical need for different dosage form and/or higher dosage — specify dosage forms/doses tried, outcomes, and medical reason
- Request for formulary tier exception — specify formulary/preferred drugs tried and results, adverse outcomes, therapeutic failure details, or contraindications
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
| ICD-10 | Diagnosis codes requested for indication |
What Providers / Prescribers Must Do
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
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
Key Definitions
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