CurrentAmeriHealthPolicy N/A

Coverage Determination Request Form

A pharmacy/coverage determination request form used by providers to request prior authorization, non-formulary coverage, step therapy exceptions, quantity limit exceptions, tier exceptions, and continuation of therapy for medications. Collects provider, patient, medication and clinical justification information and attestation for special cases (opioids, high-risk medications in elderly).

Policy Summary

PayerAmeriHealth

PolicyCoverage Determination Request Form

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionProviders must complete required provider, member, medication, clinical information, diagnosis, ICD-10 code(s), prior medication trials/contraindications, and any supporting documentation; requests may be denied unless all required information is received.

POLICY UPDATE CHANGES

No material clinical/coverage changes — form is informational and collects required data for coverage determination requests.

5Request types supported on form

90 MMEOpioid high-dose threshold

7 dayOpioid default day supply limit

Coverage Determination Request Form — Summary

This form is a pharmacy/coverage determination request used by providers to request coverage decisions including Non-Formulary, Prior Authorization, Step Therapy, Quantity Limit exceptions (including the requested quantity per DAY) and Tier Exception (Lower Copay), and to indicate continuation of therapy when applicable.

Special attestations collected on the form include: opioid-specific attestations — provider must attest if opioid therapy exceeds 90 MME per day and must attest if a requested day supply exceeds the default 7 day supply limit; and for patients aged ≥ 65 years, a checkbox to indicate whether a risk-versus-benefit assessment has been completed for a high-risk medication (HRM).

Types of Coverage Determinations Supported

Types of Coverage Determination Requested

Provider selects one or more request types

Non-Formulary - Request is for a drug not on the plan's list of covered drugs.
Prior Authorization - Request is for a drug that requires prior authorization under the plan. (Note: specific clinical questions may apply.)
Step Therapy - Request is for an exception to the requirement to try another drug first.
Quantity Limit - Request is for an exception to the plan's quantity limit. Quantity per DAY requested must be specified.
Specify quantity per DAY requested.
Tier Exception (Lower Copay) request - Request for a lower copayment because there are other drugs that treat the same condition at the lower copayment. (Does not apply to Specialty tier and is limited to the initial coverage phase.)

Continuation of Therapy

Provider indicates if request is continuation

Continuation of Therapy: Check if request is for continuation of therapy

Required Provider Actions and Attestations

Documentation Required

Complete required form fields

Providers must complete all required form fields including provider and member information, medication details, clinical information, diagnosis and ICD-10 code(s), prior medication trials/contraindications, and any supporting documentation. Requests may be denied unless all required information is received.

Prior Authorization

Prior Authorization / Exception request

Select the appropriate coverage determination type (Non-Formulary, Prior Authorization, Step Therapy, Quantity Limit, Tier Exception) and provide clinical justification, including medications tried and failed or contraindications, and any supporting information necessary for review.

Documentation Required

Quantity limit supporting evidence

For quantity limit exception requests, indicate whether the requested quantity and dose are within FDA-approved maximum dosing limits or supported by peer-reviewed medical literature, accepted standards of medical practice, and/or medical compendia. If yes, specify the supporting information on the form.

Documentation Required

Opioid attestations

For opioid therapy requests that exceed thresholds, the provider must attest on the form that the higher opioid dose or longer day supply is medically necessary: attest that opioid therapy above 90 MME per day is medically required, and attest that a requested day supply exceeding the current 7 day supply limit is medically necessary.

Opioid MME threshold: 90 MME per day
Opioid day supply threshold: 7 day supply

Documentation Required

High-risk medications in elderly

For patients aged 65 years or older who are prescribed high-risk medications, providers must indicate on the form whether a risk-versus-benefit assessment has been completed for the HRM request.

Special Attestations and Definitions

Opioid-specific Attestations

>90 MME Attestation: For opioid therapy that exceeds 90 morphine milligram equivalent (MME), provider must attest that opioid therapy above 90 MME per day is medically required.90 MME per day
Yes/No checkbox
>7 Day Supply Attestation: For opioid requests exceeding 7 day supply limit, provider must attest that in his/her clinical judgment, the requested day supply exceeding the current 7 day supply limit is medically necessary.7 day supply
Yes/No checkbox

High-Risk Medication in Elderly (>= 65 years)

Applies to patients ≥ 65 years only

High-Risk Medication in Elderly (>= 65 years): Provider indicates whether a risk versus benefit assessment has been completed for this request of a high risk medication (HRM) in an elderly patient.

Yes/No checkbox

Quantity Limit Requests - Additional Attestations

High risk if med/dose changed: Is there a high risk of significant adverse clinical outcome with medication change or dosage change?
Yes/No checkbox
Quantity/dose within FDA or supported: Is the requested quantity and dose within FDA approved maximum dosing limits or supported by peer-reviewed medical literature, accepted standards of medical practice and/or medical compendia? If yes, specify supporting information.
Yes/No checkbox; If yes, specify supporting information.

Definitions

MMEMorphine milligram equivalent (used to measure opioid dose)

HRMHigh Risk Medications in the elderly (examples: estrogens, sulfonylureas such as glyburide, hypnotics such as zolpidem, muscle relaxants such as cyclobenzaprine)

Who and What This Form Covers

Scope

Scope summaryForm used by providers to request prior authorization, non-formulary coverage, step therapy exceptions, quantity limit exceptions, tier exceptions, and continuation of therapy; collects provider, patient, medication, clinical justification information and includes attestations for opioids and high-risk medications in elderly.

Policy Summary

PayerAmeriHealth

PolicyCoverage Determination Request Form

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

On This Page

OpenPayer

Coverage Determination Request Form

Coverage Determination Request Form — Summary

Types of Coverage Determinations Supported

Required Provider Actions and Attestations

Special Attestations and Definitions

Who and What This Form Covers

Document Revision History