CurrentAvMedPolicy N/A

Medicare Coverage Determination Request (Spanish)

A Spanish-language form and instructions for Medicare members or their prescribers/representatives to request coverage determinations from AvMed/Express Scripts for prescription drug exceptions, prior authorizations, level exceptions, quantity-limit exceptions, expedited (accelerated) decisions, reimbursements, and related documentation.

Policy Summary

PayerAvMed

PolicyMedicare Coverage Determination Request (Spanish)

Policy CodePolicy N/A

Change TypeAdministrative form/instructions (no coverage change)

Effective Date

Next Review Date

Key ActionPrescriber's statement is required for formulary and tier exceptions; prior authorization requests may also require supporting clinical information and medication history.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported.

9Request types listed

24/7Phone/web availability

Document overview

This is a Spanish-language AvMed/Express Scripts Medicare prescription drug coverage determination request form used to request formulary exceptions, prior authorizations, quantity-limit exceptions, tier/level exceptions, transition exceptions, expedited (accelerated) reviews, and reimbursement requests. It collects member, prescriber, diagnosis (including ICD-10), medication history, safety, and related disclosure information to support the request.

Intended users: Medicare members (afiliados), prescribers (recetadores), and authorized representatives who act on a member’s behalf. Submission channels: by mail or fax to Express Scripts Medicare Reviews (address and fax shown on the form), by phone at 1-800-935-6103 (TTY 1-800-716-3231) available 24 hours a day, 7 days a week, or online via https://www.express-scripts.com/pa.

Types of coverage determination requests

Select the applicable request type:

Formulary exception: Exception to the plan's drug formulary (formulary exception)
Transition exception: Exception because a drug was removed from the formulary during the plan year (transition exception)
Prior authorization request for prescribed medication
Step therapy exception: Exception to step therapy (requirement to try another medication before the requested drug)
Quantity limit exception: Exception to the plan's quantity limit (quantity limit exception)
Tiering lower-tier exception: Tiering/level exception to obtain a lower copay tier
Tiering increase exception: Tiering/level exception because drug moved to a higher copay tier
Billing/pay back request: plan charged higher copay than appropriate
Reimbursement request: Request for reimbursement of a covered drug paid out-of-pocket by member

Coverage stance: Informational. This document is a form and instruction set to guide submission of coverage determination requests and does not itself define clinical coverage criteria. It explains how to request exceptions, prior authorizations, and expedited reviews and what supporting information the prescriber must provide, but it is not a policy establishing coverage rules.

Expedited (accelerated) decision criteria and provider obligations

Expedited (accelerated) decision

Conditions and process for requesting an expedited decision:

Harm from waiting standard period: Member or prescriber believes waiting 72 hours for a standard decision could seriously harm life, health, or ability to regain maximum function
Prescriber-supported expedited leads to 24-hour decision: If prescriber indicates harm from waiting, plan will automatically provide a decision within 24 hours
Plan may determine expedited without prescriber support: If prescriber support is absent, plan will determine if expedited review is warranted
Exclusion for reimbursement requests: Cannot request expedited determination for reimbursement of a drug already received

Prior Authorization

Expedited decision process

Prescriber must state that waiting 72 hours for a standard decision could seriously harm the member; if the prescriber indicates such harm the plan will automatically provide a decision within 24 hours. If the prescriber does not support the expedited request, the plan will evaluate whether expedited review is warranted. Expedited review cannot be requested for reimbursement of a drug already received.

Prescriber must explicitly indicate that waiting 72 hours could seriously harm life, health, or ability to regain maximum function.
When prescriber indicates harm, plan will automatically grant a 24-hour decision.
Absent prescriber support, plan will determine if expedited review is warranted.
Expedited determination not available for reimbursement requests for drugs already received.

Prior Authorization

Prescriber must provide supporting statement for exceptions

A prescriber's supporting statement is required for formulary and tier (level) exception requests. Prior authorization requests may also require supporting clinical information and medication history. The prescriber should provide the drug name (including concentration and monthly quantity if known), intended regimen, diagnoses with ICD-10 codes, medication trial history with dates and outcomes (including inefficacy or intolerance), and any safety or monitoring rationale.

Attest that the formulary or tier exception is clinically warranted.
Provide drug name, concentration, quantity per month (if known), and intended regimen.
List diagnoses with ICD-10 codes and medication trial history with dates and outcomes (inefficacy/intolerance).
Describe safety concerns, monitoring, and risk/benefit if applicable.

Required documentation and clinical information

Required documentation for exception or prior authorization

Requests for formulary or tier exceptions require prescriber supporting statement; prior authorizations may require supporting information:

Prescriber statement: Prescriber's statement supporting exception requests is required
See form: 'Las solicitudes de EXCEPCIÓN DE FORMULARIO y NIVEL no se pueden procesar sin una declaración de respaldo del recetador.'
Representation documentation: Attach documentation of representation if someone other than member or prescriber submits (CMS-1696 or equivalent)
Drug details: Provide drug name, concentration, quantity per month (if known), and intended regimen
Diagnoses and treatment history: Provide diagnoses with ICD-10 codes and treatment history with dates, outcomes, inefficacy or intolerance
Safety concerns: For safety concerns, indicate FDA contraindications or drug-drug interaction concerns and explain monitoring and risk/benefit
Geriatric affirmation: For patients >65, prescriber must affirm benefits outweigh risks for high-risk medications in older adults
Opioid-specific data: For opioids, provide MED (morphine equivalent dose mg/day), other prescribers, and justification of necessity

Documentation Required

Required clinical information on form

The form requires detailed clinical information: all diagnoses treated with the requested medication with ICD-10 codes; medication trial history including dates, results, and any inefficacy or intolerance; the patient's current medication regimen; allergies; and relevant safety concerns such as FDA contraindications, drug–drug interaction issues (with explanation, benefits/risks, and monitoring plan), and for opioids the morphine equivalent daily dose (MED) and related prescriber information.

Diagnoses with ICD-10 codes for all conditions treated by the requested drug.
Medication trial history with dates, results, and documentation of inefficacy or intolerance.
Current medication regimen and quantity per 30 days.
Allergies to medications.
Safety concerns: FDA contraindications, interactions (explain, risk/benefit, monitoring).
If opioid: report MED (mg/day), other prescribers, and justification of necessity.

Documentation Required

Documentation of representation when submitted by third party

If someone other than the member or prescriber submits the request, attach documentation authorizing that person to act on the member's behalf (a completed CMS-1696 form or an equivalent written authorization).

CMS-1696 is the CMS standard form for designation of a representative to act on behalf of a Medicare beneficiary.

Submission channels and contact information

Billing Rule

Submission channels and contact

Requests may be submitted by mail or fax to Express Scripts Attn: Medicare Reviews (PO Box 66587, St Louis, MO 63166-6587) or via the web portal. Phone assistance is available 24 hours a day, 7 days a week at 1-800-935-6103 (TTY 1-800-716-3231). Fax and web PA portal details are provided on the form.

Phone: 1-800-935-6103 (TTY 1-800-716-3231) — available 24/7
Web PA portal: https://www.express-scripts.com/pa
Mail: Express Scripts Attn: Medicare Reviews, PO Box 66587, St Louis, MO 63166-6587
Fax: 1-877-328-9660

Operational notes: If someone other than the member or the prescriber submits the request, attach documentation authorizing representation (a completed CMS-1696 form or equivalent written authorization). Include supporting clinical documentation and any attachments referenced on the form (medication history, diagnoses with ICD-10 codes, prescriber statement, and safety information).

Término	Definición
Solicitud de determinación acelerada
Request for expedited review when waiting 72 hours could seriously harm life, health, or ability to regain maximum function; may result in a 24-hour decision.
CMS-1696
CMS standard form for designation of a representative to act on behalf of a Medicare beneficiary.