CurrentAetnaPolicy N/A

Request for Medicare Drug Coverage Determination (Coverage Criteria)

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.

Policy Summary

PayerAetna

PolicyRequest for Medicare Drug Coverage Determination (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit prescriber-completed supporting information including diagnosis with ICD-10 codes, medication details, drug trial history, and rationale for exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24hexpedited decision turnaround

72hstandard decision timeframe

1-866-235-5660coverage request phone

1-855-633-7673fax number

When Coverage Determinations or Exceptions are Supported

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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:

Types of requests: Formulary exception (non-covered drug, removed drug, waiver of prior authorization or quantity limit), prior authorization, reimbursement for out-of-pocket payment, tiering exception

Refer to items on form for specific request type

Prescriber documentation required: Diagnosis with ICD-10 code(s), medication details (dose, frequency, route, start date, quantity), drug history with dates and outcomes (failure vs intolerance), rationale for exception including prior trials or contraindications

Supporting pages 3-4 to be completed by prescriber

Rationale categories: Previous drug trials failed or caused adverse outcomes; alternative drugs contraindicated or likely less effective; patient would suffer adverse effects if required to satisfy prior authorization or step therapy; patient stable on current drug and at high risk if changed; medical need for different dosage form or higher dosage

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

Requested diagnoses (ICD-10)ICD-10

ICD-10

Diagnosis codes for conditions being treated with the requested drug

Morphine Equivalent Dose (MED) — prescriber-entered

Morphine Equivalent Dose (MED)Specified as the daily cumulative MED in mg/day as entered by the prescriber on the form

Required responderPrescriber must complete the MED field when the requested drug is an opioid

Supporting questionsForm asks whether other opioid prescribers are involved and whether the stated MED is medically necessary

Clinical adequacyForm asks if a lower total daily MED would be insufficient to control the enrollee's pain

Prescriber Documentation & Submission Requirements

Documentation Required

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

Prior Authorization

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

Denial Risk

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

Expedited decision — 24-hour review criteria

DefinitionAn expedited decision is a faster review resulting in a decision within 24 hours when the prescriber indicates that waiting the standard 72 hours could seriously harm life, health, or ability to regain maximum function

When to requestRequester or prescriber believes waiting 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function

Evidence neededAttach a supporting statement from the prescriber to the request to ensure automatic 24-hour processing

LimitationExpedited review is not available for requests to be reimbursed for a drug already received

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.

Initial therapy documentation: List prior drugs tried with dates, results (failure vs intolerance), maximum dose and length of therapy if therapeutic failure claimed

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

Requested drug — exception to quantity limit

Quantity limit exceptionA prescriber may request an exception to the plan's quantity limit for the requested drug by providing supporting documentation on the form

Required documentationProvide medication details (dose, frequency, route, start date, quantity) and rationale such as prior drug trials, contraindications, or medical need for different dosage or higher dose

Rationale examplesDocumented prior trials with adverse outcome or therapeutic failure; alternatives contraindicated or likely less effective; patient stable on current drug and at high risk if changed

Form sections to completePrescriber should complete the Supporting Information pages (pages 3–4) including drug history and rationale fields