Coverage Determination Request Form
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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).
No material clinical/coverage changes — form is informational and collects required data for coverage determination requests.
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.
The form collects required provider, member, medication, clinical justification, diagnosis/ICD-10 code(s), prior medication trials/contraindications and supporting documentation necessary to evaluate the request; requests may be denied unless all required information is received.
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).
The form also provides multilingual interpreter contact information for free interpreter services to assist non-English-speaking members and providers.
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
Required Provider Actions and Attestations
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 / 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.
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.
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
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
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.
Who and What This Form Covers
Document Revision History
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.