CurrentAspirus ArisePolicy N/A

Request for Medicare Prescription Drug Coverage Determination Form (PDF)

A plan-provided form for enrollees, prescribers, or authorized representatives to request Medicare prescription drug coverage determinations, including prior authorization, formulary exceptions, tiering/quantity exceptions, expedited review requests, and reimbursement claims.

Policy Summary

PayerAspirus Arise

PolicyRequest for Medicare Prescription Drug Coverage Determination Form (PDF)

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionFor formulary exceptions and prior authorization requests the prescriber MUST complete the Supporting Information section with diagnosis (ICD-10), drug history, safety information, rationale, and sign/date the form.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — the form operationalizes existing Medicare Part D coverage determination requests and contains no material policy changes.

11Request types supported by form

24/72Decision timeframes (hours) with prescriber support / standard

Policy overview & quick facts

This form operationalizes the Medicare Part D coverage determination process and is used to ask the plan for coverage determinations related to prescription drugs. It collects enrollee and prescriber information, drug history, diagnoses (ICD-10), clinical rationale, and other supporting information needed to evaluate requests.

The form may be used by the plan enrollee, the enrollee's prescriber, or an authorized representative acting on the enrollee's behalf to request coverage determinations including prior authorization, formulary exceptions, tiering and quantity limit exceptions, expedited review requests, and reimbursement requests.

Types of requests supported

Types of Requests Covered by the Form

Use this form to request one of the following coverage determinations:

ANY of the following

Higher copayment charged for a drug than should have been charged
Reimbursement for a covered drug already paid out of pocket
Prior authorization for a prescribed drug (may require supporting information)
Formulary exception: drug not on plan's list of covered drugs
Formulary exception: drug not on formulary and request is for a brand when a generic/biosimilar is available (supporting documentation required)
Formulary exception: drug previously covered but removed during plan year
Formulary exception: exception to step therapy (requirement to try another drug)
Formulary exception: exception to quantity limit (to obtain prescribed number of pills)
Formulary exception: exception to prior authorization rules
Tiering exception: request lower copayment tier because plan charges higher copayment than for another drug treating same condition
Tiering exception: drug moved from a lower to higher copayment tier

Coverage stance: informational. This document is a form to request Medicare Part D coverage determinations from the plan; submitting the form requests a coverage decision but is not itself an authorization.

Expedited decision (fast) criteria

Expedited Decision Criteria

Criteria for requesting an expedited (fast) decision:

ALL of the following

Prescriber believes waiting 72 hours for a standard decision could seriously harm enrollee's life, health, or ability to regain maximum function
If prescriber provides supporting statement, plan will automatically give decision within 24 hours24 hours
Prescriber must indicate support or attach statement
If no prescriber support, plan will decide if case requires a fast decision72 hours
Plan evaluates need for expedited review when prescriber support absent
Expedited decision not available for requests for reimbursement of a drug already received
Expedited review cannot be requested for reimbursement requests

Prior Authorization

Expedited review request

If prescriber attests that applying the standard 72-hour review timeframe may seriously jeopardize the enrollee's life, health, or ability to regain maximum function, check the expedited review box and sign; with prescriber support the plan will decide within 24 hours.

Check the REQUEST FOR EXPEDITED REVIEW / expedited box on the prescriber section
Prescriber must sign and date the form to trigger the 24-hour decision when prescriber support is provided

Prescriber supporting information required

Prescriber Supporting Information Required

For certain request types, prescriber MUST provide supporting statement and complete the prescriber section:

ALL of the following

Prescriber information: name, address, office phone, fax, signature, date
Completed in Prescriber Information section
Diagnosis and medical information: medication, strength/route, frequency, date started, new start vs continuation, expected length of therapy, quantity per 30 days, height/weight, drug allergies
Includes ICD-10 codes for diagnoses
ICD-10 code(s) for diagnoses being treated and other relevant diagnoses
Listed in Diagnosis section
Drug history: drugs tried, dates, results (failure vs intolerance) and current drug regimen
Document prior trials and outcomes
Drug safety: FDA contraindications and drug interaction concerns with explanation and monitoring plan if yes
If yes, explain issue, benefits vs risks, and monitoring plan
High risk management for patients >65: prescriber assessment that benefits outweigh risks (YES/NO)
Response required if enrollee >65
ALL of the following
- Rationale options (at least one applies)
  - Alternate drugs tried but had adverse outcome or therapeutic failure (details required)
    Provide drugs tried, adverse outcomes, doses and durations
  - Alternative drugs contraindicated or less effective with specific explanation
    Explain why alternatives are contraindicated or less effective
  - Patient would suffer adverse effects if required to satisfy prior authorization (explanation required)
    Describe anticipated significant adverse clinical outcome
  - Patient is stable on current drug(s) with high risk of adverse outcomes if changed (explanation required)
    Explain why medication change risks significant adverse outcomes

Documentation Required

Prescriber must complete supporting information for certain requests

For formulary exceptions and prior authorization requests the prescriber MUST complete the Supporting Information section, providing diagnosis (ICD-10), drug history, drug safety information, clinical rationale, and sign/date the form.

Diagnosis with ICD-10 code(s)
Drug history: drugs tried, dates, and results (failure vs intolerance)
Drug safety information: contraindications, interactions, monitoring plan
Clinical rationale (one or more applicable rationale options)
Prescriber's signature and date

Documentation Required

Representative authorization

If the person submitting the request is not the enrollee or the prescriber, include documentation showing authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or equivalent).

Submission instructions

Prior Authorization

Prior authorization and exception submission

Submit this form with supporting documentation (and any representation authorization if applicable) by mail or fax to request prior authorization, formulary exceptions, tiering exceptions, quantity limit exceptions, or reimbursement.

Mail: PO Box 1039, Appleton, WI 54912-1039
Fax: 1-855-668-8552
Include supporting documentation and representation authorization (e.g., CMS-1696) if applicable

This form supports requests for prior authorization, formulary exceptions (including tiering and quantity limit exceptions), reimbursement for covered drugs paid out-of-pocket, and requests for expedited review. The Types of Request section lists these supported request categories and notes when prescriber supporting information is required.

For certain request types the prescriber must complete the Supporting Information section and provide diagnosis (ICD-10), drug history, safety information, rationale, and signature/date. Ensure all required documentation and signatures are included with the submission to avoid processing delays.

Definitions

Expedited decision: a fast decision provided within 24 hours if the prescriber attests that waiting the standard 72-hour timeframe could seriously harm the enrollee; if no prescriber attestation is provided, the plan will evaluate whether expedited review is warranted.

Formulary exception: a request to cover a drug not on the plan's list of covered drugs or to override formulary restrictions such as step therapy, tiering, or quantity limits (this may require prescriber supporting documentation as specified in the form).