CurrentAmeriHealthPolicy N/A

Request for Medicare Drug Coverage Determination (Form and Coverage Criteria)

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Form and instructions for requesting a Medicare drug coverage determination (prior authorization, formulary exception, reimbursement, tiering or quantity limit exceptions) from AmeriHealth; intended for plan enrollees, prescribers, or authorized representatives submitting requests.

Policy Summary

PayerAmeriHealth

PolicyRequest for Medicare Drug Coverage Determination (Coverage Criteria & Form)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed form with prescriber supporting documentation including diagnosis (ICD‑10), medication details, drug history, and rationale to request coverage or exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24form fields and checkboxes (approx.)

24/7phone/web submission options

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CurrentAmeriHealthPolicy N/A

Request for Medicare Drug Coverage Determination (Form and Coverage Criteria)

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Sign up for all AmeriHealth policy alerts

Know when AmeriHealth releases new policies or updates existing guidance.

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Policy Summary

PayerAmeriHealth

PolicyRequest for Medicare Drug Coverage Determination (Coverage Criteria & Form)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed form with prescriber supporting documentation including diagnosis (ICD‑10), medication details, drug history, and rationale to request coverage or exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24form fields and checkboxes (approx.)

24/7phone/web submission options

Coverage determination criteria

Documentation and medical necessity

Covered when ALL of the following required documentation elements are submitted and justify the requested coverage determination (prior authorization, formulary exception, quantity limit exception, tiering exception, or reimbursement).

Required elements for review: All of the following must be submitted: completed request form; prescriber statement when required; diagnosis with ICD-10 code(s); medication details (name, strength, route, frequency, quantity per 30 days); drug history including trials, dates, outcomes and whether failure or intolerance; documentation of contraindications or reasons alternatives are not suitable; rationale for exception (e.g., stable on current therapy, medical need for different dosage form, prior adverse effects).

Supported by form sections: Type of Request; Prescriber Information; Diagnosis and Medical Information; Drug History; Rationale for Request

Types of requests that require prescriber statement: A prescriber MUST provide a statement when the request is any of the following: formulary exception (including drugs not on formulary, removal from formulary, exceptions to step therapy, quantity limit exceptions, or exceptions to prior authorization rules).

See Type of Request checkboxes identifying request types that require prescriber completion of Supporting Information for an Exception Request or Prior Authorization.

Clinical details required in prescriber submission: Prescriber must document: diagnoses being treated with corresponding ICD-10 code(s); medication name, strength, route, frequency, date started, expected length of therapy, and quantity per 30 days; height/weight and drug allergies where relevant.

Captured in Diagnosis and Medical Information section of the supporting information form.

Drug history and prior trials: Provide complete drug history for the condition: drugs tried (including unit dose/total daily dose if quantity limit issue), dates of trials, results, and whether failure or intolerance. Explain current regimen and why alternative medications would not be as effective or would cause adverse effects.

See DRUG HISTORY section; required when requesting step therapy or formulary/tiering exceptions.

Step therapy / prior authorization exceptions: To request an exception to step therapy or to bypass prior authorization requirements, prescriber must include a statement documenting prior trials and failures, contraindications, or intolerance that justify bypassing step requirements, and explain why alternatives are not suitable.

Supported by RATIONALE FOR REQUEST items describing required details for alternatives tried, contraindications, and clinical rationale.

Rationale elements for formulary tier or quantity exceptions: When requesting tiering or quantity limit exceptions, include: formulary/preferred drugs tried and results; if adverse outcome occurred, list drugs and adverse outcomes; if therapeutic failure, list maximum dose and length of therapy for drugs trialed; or specific clinical reasons why preferred drugs are contraindicated or not suitable.

See RATIONALE FOR REQUEST checkboxes for formulary tier exception and quantity/alternative explanations.

Expedited review request: If expedited review is requested, the prescriber must certify that applying the 72-hour standard review timeframe may seriously jeopardize the enrollee's life, health, or ability to regain maximum function. Expedited requests are documented by checking the expedited review box and signing the form.24 hours

REQUEST FOR EXPEDITED REVIEW checkbox and certification required; expedited timeframe is 24 hours when criteria met.

Safety and contraindication disclosure: Disclose any FDA-noted contraindications to the requested drug and explain; document concerns for drug interactions or other safety issues that affect medical necessity.

DRUG SAFETY section asks about FDA-noted contraindications and interaction concerns.

Operational/documentation notes: Include representative authorization (e.g., CMS-1696) if the requester is not the enrollee. Submit any supporting documents referenced on the form (clinical notes, lab results, hospitalization records) to substantiate trials, failures, contraindications, or adverse outcomes. Failure to provide required prescriber supporting information may result in denial or incomplete processing.

Supported by Required supporting documentation and Missing supporting prescriber documentation guidance.

Expedited (fast) decision requests are available when the prescriber or enrollee believes that waiting the standard 72-hour decision period could seriously harm the enrollee's life, health, or ability to regain maximum function. In those cases, a request supported by the prescriber will be handled within 24 hours. However, an expedited decision is not available for reimbursement claims for drugs already received; you cannot request expedited review solely to obtain payment after the drug has been dispensed.

Diagnosis codes and review timeframes

Diagnosis codesICD-10

ICD-10

Space to list ICD-10 diagnosis codes for conditions being treated with the requested drug

Expedited decision timeframe

Expedited decision timeframeDecision provided within 24 hours when prescriber indicates waiting 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function.

When prescriber support absentIf prescriber support for expedited request is not provided, the plan will determine whether a fast decision is required.

Not available for retrospective reimbursementCannot request expedited review for reimbursement claims for drugs already received.

Standard decision timeframe

Standard decision timeframeStandard review decision timeframe is 72 hours.

Expedited triggerAn expedited (24-hour) decision may be requested if waiting 72 hours could seriously harm the enrollee; otherwise standard timeframe applies.

What providers must submit

Prior Authorization

Prior Authorization Required

Prior authorization requests require completion of the prescriber section and submission of supporting clinical information. The prescriber must provide the diagnosis (with ICD‑10 code[s]), medication name, strength, route, frequency, quantity, dates of drug trials, results (failure vs intolerance), current regimen, and expected length of therapy. Incomplete or missing prescriber information may result in return of the request or denial.

Include prescriber-completed 'Supporting Information for an Exception Request or Prior Authorization' (pages 3–4) with the request.
Provide diagnosis(es) and corresponding ICD‑10 code(s).
List medication details: name, strength, route, frequency, quantity per 30 days, date started, and whether this is a new start.
Document drug history: drugs tried for the condition, dates of trials, results (failure vs intolerance), and reasons alternatives are not suitable.
Describe current drug regimen and any drug interactions or contraindications, with monitoring plan if safety concerns exist.
If applicable, check and justify expedited review request.

Policy background

This form is used to capture the clinical information required to evaluate Medicare drug coverage determinations, including formulary exceptions, prior authorizations, quantity-limit exceptions, tiering exceptions, and reimbursement requests. It collects enrollee and prescriber identification, the specific diagnosis with ICD-10 code(s), medication details (drug name, strength, route, frequency, and quantity per 30 days), drug history (drugs tried, dates, outcomes, failure versus intolerance), and any FDA-noted contraindications or drug-interaction concerns.

Prescribers must provide a clinical rationale when requesting exceptions or prior authorization: documentation of prior trials and outcomes, reasons alternatives are not appropriate (contraindication, intolerance, or therapeutic failure), and safety considerations. The form also includes sections to explain requests for formulary tier exceptions or reimbursement and space to list the drugs tried and the results to support medical necessity.

Key definitions

Expedited review definition

DefinitionAn expedited review is an accelerated decision process that results in a decision within 24 hours when waiting the standard 72-hour timeframe could seriously harm the enrollee's life, health, or ability to regain maximum function.

Prescriber certificationPrescriber certifies expedited review by checking the REQUEST FOR EXPEDITED REVIEW box and signing the prescriber form, stating that applying the 72-hour standard review timeframe may seriously jeopardize the enrollee's life or health.

Automatic timingIf the prescriber indicates that waiting 72 hours could seriously harm the enrollee, the plan will automatically give a decision within 24 hours.

Step therapy exception requirements

Prescriber explanation of why alternatives are not suitable	Drugs tried (name, max dose, duration)	Results (therapeutic failure, intolerance, adverse outcome)	Specific contraindication or anticipated adverse clinical outcome
Must include a prescriber statement explaining why alternative drug(s) would not be as effective or would likely cause an adverse outcome; when claiming contraindication, provide specific reasons why preferred/formulary drugs are contraindicated.
List drug(s) tried with maximum dose and length of therapy for each trial (if not already in the Drug History section).
Document results of each trial: therapeutic failure, intolerance, toxicity, allergy, or other adverse outcome; if therapeutic failure, specify maximum dose and duration tried.
If asserting a likely adverse clinical outcome from using alternatives, provide a specific explanation of the anticipated significant adverse clinical outcome and why it would be expected (e.g., hospitalization, myocardial infarction, stroke, falls, loss of function).

Quantity limit exception requests

Requested drug quantity

Quantity per 30 daysProviders must specify the requested quantity per 30 days in the 'Quantity per 30 days' field on the form.

Request exception if plan limit appliesIf a plan quantity limit applies, request an exception and provide drug history and rationale (e.g., medical need for higher dosage form, dosing history) to justify the exception.

Drug details to captureInclude medication name, strength, route, frequency, date started, expected length of therapy, and whether this is a new start.

Supporting rationaleProvide rationale for request including prior drugs tried, outcomes, contraindications, or medical need for different dosage form as applicable.