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Request for Medicare Drug Coverage Determination (Coverage Criteria)
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Form and instructions used by Medicare plan enrollees, prescribers, or authorized representatives to request coverage determinations, prior authorizations, formulary exceptions, expedited reviews, or reimbursement from the plan. Affects SilverScript/Aetna Medicare prescription drug plan enrollees and their prescribers.
No material clinical or coverage changes in this revision.
When Coverage Determinations or Exceptions are Supported
When coverage determinations or exceptions are supported
Coverage determination requests are evaluated when the prescriber provides required supporting information. Examples of reasons to request coverage include:
Refer to items on form for specific request type
Supporting pages 3-4 to be completed by prescriber
Form lists checkboxes and asks for specifics
Expedited (24-hour) review is not available for requests that ask the plan to reimburse the enrollee for a drug already received. The form states that an expedited decision is provided when the prescriber certifies that waiting the standard 72-hour timeframe could seriously harm the enrollee’s life, health, or ability to regain maximum function, but explicitly prohibits expedited requests solely for reimbursement of a drug that has already been dispensed.
Requested Diagnoses and Dosing Codes
| ICD-10 | Diagnosis codes for conditions being treated with the requested drug |
Prescriber Documentation & Submission Requirements
Prescriber Supporting Information Required
Prior authorization and formulary exception requests require prescriber-completed supporting information. The prescriber must provide clinical details to support the request, including diagnosis (with ICD-10 codes), medication details (name, strength, route, frequency, quantity, expected length of therapy, date started), current drug regimen, drug allergies, and the enrollee's drug history (dates of trials, results, and whether prior agents failed or were not tolerated).
- Diagnosis with corresponding ICD-10 code(s)
- Medication name, strength, route, frequency, quantity per 30 days, and expected length of therapy
- Date medication was started and whether this is a new start
- Current drug regimen and drug allergies
- Drug history including dates of prior drug trials, results, and specification of failure vs intolerance
- Clinical rationale: alternatives tried and why contraindicated or ineffective, risk of harm from requiring step therapy or a medication change, need for different dosage form or higher dosage
Formulary Exception — Document Prior Trials or Contraindication
Formulary exception requests must document prior use of formulary or preferred drugs and provide evidence of failure, intolerance, contraindication, or otherwise explain why step therapy or other formulary requirements should be waived. Include details of prior trials (drug names, maximum dose, length of therapy, and outcomes) or specific clinical reasons why alternatives are not appropriate.
- If requesting a tier or formulary exception, list formulary/preferred drugs tried, dates, doses, duration, and outcomes
- If contraindication, provide specific clinical explanation for each preferred drug
- If therapeutic failure, include maximum dose tried and length of therapy
Incomplete Submission May Result in Denial
Requests may be denied if required supporting prescriber information is not provided or is incomplete. Failure to submit the prescriber-completed sections (including diagnosis with ICD‑10 codes, drug history, medication details, and rationale) for prior authorization or formulary exception requests may result in denial. Be sure to include any supporting documents and, if applicable, a completed Authorization of Representation when the requester is not the enrollee.
- Incomplete or missing prescriber supporting information can lead to denial of the request
- Include Authorization of Representation (CMS-1696 or equivalent) when requester is not the enrollee
- Attach any relevant medical records or documentation supporting the rationale
Purpose of This Form
This form is intended to collect the clinical and administrative information needed to evaluate Medicare Part D coverage determinations, including requests for prior authorization, formulary exceptions, quantity‑limit exceptions, tiering exceptions, expedited review, or reimbursement. For expedited review, the requester must demonstrate that waiting the standard 72-hour decision timeframe could seriously harm the enrollee; with prescriber support the plan will issue a decision within 24 hours. If prescriber support is not provided, the plan will determine whether a fast decision is warranted.
Key Definitions
Initial Therapy / Prior-Trial Documentation
Initial therapy / prior-trial documentation
When requesting coverage for an initial therapy or an exception due to prior failures, prescriber must document previous drug trials and results.
Required for formulary exceptions and many prior authorizations
Step Therapy & Formulary Exception Requirements
| Requirement | Details / Provider must document |
|---|---|
| Explain why step therapy should be waived | A specific explanation why alternative drug(s) are contraindicated, would not be as effective, or are likely to cause a significant adverse clinical outcome; include why the alternative is expected to be ineffective or harmful |
| Document prior use and outcomes of preferred/step drugs | List alternate or preferred drug(s) previously tried with dates and results; if therapeutic failure, provide maximum dose and length of therapy; if adverse outcome, describe the adverse outcome for each drug |
| Provide clinical rationale if patient stable on current drug | Explain why changing therapy would pose high risk of significant adverse clinical outcome (e.g., prior hospitalization, loss of function, severe symptoms); provide specific anticipated outcomes and reasons |
| If contraindication claimed, provide specifics | List specific reason(s) why preferred/formulary drug(s) are contraindicated for this patient |
| Request for formulary tier or dosage-form exception | If requesting tier exception or different dosage form/higher dose, specify formulary/preferred drugs tried and results, adverse outcomes if any, and medical reason for needed dosage form or strength |
Quantity Limit Exceptions
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