Medicare Part D Coverage Determinations and Exceptions
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Defines procedures for prior authorization and formulary exception requests for Medicare Part D drugs, who may request them, timelines for decisions, and appeal/representative processes for Aspirus Health Plan Medicare members and their providers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Medical Necessity
Administrative coverage criteria
Covered when the following administrative conditions are met:
Aspirus encourages use of the Request for Medicare Prescription Drug Coverage Determination Form or Physician Prior Authorization and Exception Forms
Expedited requests may be requested when waiting could seriously harm the member; timelines run from receipt of the prescribing physician's supporting statement
Coverage determinations under this policy are administrative decisions about whether Medicare Part D benefits will be provided for a requested drug. They are not clinical practice guidance. Two administrative pathways are described: Prior Authorization and Formulary Exception. Prior authorization requires a signed statement or form from the prescribing physician explaining why the drug is medically necessary. Formulary exceptions request a waiver of coverage restrictions, a change in a drug's tier, or removal of quantity limits. Decisions are based on whether the requested drug and the supporting documentation meet the plan’s criteria for medical necessity and formulary exception standards.
Requests that fail to show that formulary alternatives would be less effective or would cause adverse medical effects are generally not approved. For a formulary exception to be granted, the documentation must demonstrate that the alternative drugs on the plan’s formulary or any additional utilization restrictions would not be as effective in treating the member’s condition and/or would cause the member to have adverse medical effects.
Provider Requirements, Prior Authorization, and Exceptions
Prior authorization required — submit form or supporting statement
Certain formulary drugs require prior authorization. The prescriber must submit a prior authorization form or a supporting statement that explains why the drug is medically necessary. Standard decisions are made within 72 hours and expedited requests within 24 hours if expedited is granted.
- Use Request for Medicare Prescription Drug Coverage Determination Form or Physician Prior Authorization and Exception Forms when possible.
- Decision timeframe: standard — 72 hours; expedited — 24 hours (if expedited granted).
Formulary exception / step therapy alternative requests
Formulary exception requests may ask Aspirus to waive coverage restrictions or quantity limits, or to change the drug’s tier (for example, from brand name to preferred brand). Exceptions will generally be approved only if formulary alternatives would not be as effective or would cause adverse medical effects.
- Request may seek waiver of coverage restrictions or quantity limits.
- Request may seek tier change (e.g., brand to preferred brand).
- Approval requires demonstrating that formulary alternatives are less effective or would cause adverse effects.
Physician supporting statement required — use recommended forms
A physician supporting statement must be submitted with the coverage determination or exception request; Aspirus encourages use of the Request for Medicare Prescription Drug Coverage Determination Form or the Physician Prior Authorization and Exception Forms.
- Form includes sections for the member and the prescribing physician to complete.
- Physician may instead use the Physician Prior Authorization and Exception Forms.
Denial risk if formulary alternatives are as effective or request not medically necessary
Requests may be denied if the alternative drugs on the plan’s formulary would be as effective in treating the condition or if the request does not demonstrate medical necessity.
- Ensure documentation shows formulary alternatives would be less effective or would cause adverse medical effects to avoid denial.
Background and Scope
This document provides administrative guidance for coverage determinations and exception requests for Aspirus Health Plan Medicare Part D members. It explains the types of requests available, the required supporting documentation from the prescriber, and the criteria the plan uses to evaluate medical necessity and formulary exceptions. It is not intended to provide clinical treatment recommendations.
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