CurrentBaylor Scott & White Health PlanPolicy N/A

Medicare Drug Coverage Determination / Prior Authorization and Formulary Exception Request

Form and instructions for Medicare enrollees, prescribers, or authorized representatives to request coverage determinations, prior authorizations, formulary exceptions, tiering exceptions, quantity limit exceptions, and expedited reviews from the plan.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMedicare Drug Coverage Determination / Prior Authorization and Formulary Exception Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must submit patient demographics, diagnosis ICD-10 codes, drug history with dates and outcomes, clinical rationale, and prescriber signature when requesting prior authorization or formulary exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24-72hdecision timeframe

833-502-3340phone

833-434-0563fax

Capital Rxmail

Coverage Determination & Review Criteria

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Documentation and clinical justification

Coverage determinations, prior authorizations, and formulary exceptions will be considered when the prescriber provides the following documented information.

Required information: Prescriber provides patient demographics; drug name, strength, route, frequency, quantity per 30 days; diagnosis(es) with ICD-10 code(s); drug history including prior trials with dates and outcomes (failure vs intolerance) and current regimen; rationale for request including contraindications to alternatives, anticipated clinical risk if medication changed, and prescriber signature.

Supports prior authorization, formulary exception, quantity limit exception, and tiering exception determinations.

Expedited Review

Expedited decision criteria

Expedited review: If prescriber certifies that waiting 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function, the plan will automatically decide within 24 hours if statement is provided; otherwise the plan will assess whether expedited review is warranted.24 hours

Cannot request expedited review for reimbursement of a drug already paid out-of-pocket.

Expedited review is not available for requests that seek reimbursement for drugs that have already been received and paid for out of pocket. Providers and enrollees should not submit an expedited decision request when the purpose of the request is to recover payment for a drug already purchased; such requests will not qualify for the expedited (24‑hour) decision pathway.

Diagnosis & Coding Information

Requested diagnosis codesICD-10

ICD-10

Diagnoses being treated with the requested drug — form requests ICD-10 code(s) for each diagnosis

Opioid MED (morphine equivalent dose)

MetricDaily cumulative Morphine Equivalent Dose (MED) in mg/day

When collectedRequested on the form when the requested drug is an opioid

Form questionsForm asks: What is the daily cumulative Morphine Equivalent Dose (MED)? (mg/day); Are you aware of other opioid prescribers? Is the stated daily MED dose medically necessary? Would a lower total daily MED dose be insufficient?

Provider Responsibilities & Submission Requirements

Prior Authorization

Prior Authorization & Prescriber Supporting Information

Prior Authorization Required — Prior authorization requests require the prescriber to complete and submit supporting clinical information. The prescriber must provide clinical justification, medication details (name, strength, route, frequency, quantity per 30 days), expected length of therapy, start date, and signature. Include patient demographic information (name, date of birth, member ID, contact information) and prescriber contact information (name, office address, phone, fax).

Include supporting documentation when requesting expedited review and certify if a 72-hour review timeframe would seriously jeopardize life or health.
Provide diagnosis(es) treated with corresponding ICD-10 code(s).

Documentation Required

Formulary Exception: Required Drug History & Rationale

Formulary Exception Documentation — When requesting a formulary or tiering exception, the prescriber must document trials of preferred/formulary drugs and reasons for failure, intolerance, contraindication, or adverse outcomes. Specify drugs tried, dates of drug trials, maximum dose and length of therapy for those trials, and detailed results (therapeutic failure, intolerance, toxicity, allergy). If requesting a tiering exception or quantity-limit exception, explain why alternatives are not appropriate and provide current drug regimen.

List each preferred drug trialed and outcome; if therapeutic failure, include maximum dose and duration tried.
If contraindicated, state specific reasons why preferred drugs are contraindicated.
For quantity-limit exceptions, list prior doses/trials and rationale for requested quantity.

Denial Risk

Denial Risk for Incomplete Requests

Denial Risk if Required Information Is Missing — Requests lacking required supporting clinical information risk denial. Missing items that may trigger denial include: prescriber statement or signature, completed supporting information form, drug history (drugs tried, dates, results), documented ICD-10 diagnosis codes, current drug regimen, and rationale for exception (e.g., contraindication, risk of significant adverse outcome if therapy changed). Attach any relevant medical records and evidence to support the request.

If the requester is not the enrollee or prescriber, submit an Authorization of Representation (e.g., CMS-1696) or equivalent.
Include any additional supporting documents referenced on the request form.

Policy Background

This administrative form is used to request Medicare drug coverage determinations including prior authorizations, formulary exceptions, quantity limit exceptions, and tiering exceptions. It collects the clinical and administrative details the plan requires to adjudicate coverage requests, including patient demographics, drug name/strength/route/frequency/quantity, ICD‑10 diagnosis codes, drug history with dates and outcomes, and the prescriber’s rationale and signature.

The form also supports requests for an expedited review when the prescriber certifies that waiting the standard 72‑hour timeframe could seriously harm the enrollee’s life, health, or ability to regain maximum function. When a prescriber provides a supporting statement that waiting could cause serious harm, the plan will automatically decide within 24 hours.

Requirement	Details
Prescriber must provide drug history and rationale to waive step-therapy.
Documentation must include trials of formulary/preferred drugs with dates, maximum dose and duration tried, and reason for failure, intolerance, or contraindication; if not captured in drug history, provide specific rationale in the 'Rationale for Request' section (e.g., toxicity, allergy, therapeutic failure, or anticipated significant adverse clinical outcome if medication changed).

Quantity Limit Exception Requests

Requested drug — quantity limit exceptions

Allowed requestRequests can be submitted to exceed plan quantity limits if the prescriber documents medical need (e.g., medical need for different dosage form or higher dosage).

Required documentationPrescriber must provide rationale describing medical need, dosage(s)/form(s) tried and outcomes, and why lower dosing or alternative options are not appropriate.

Context on formRationale for request section prompts explanation of medical need, prior drug trials, adverse outcomes, and stability on current regimen if relevant.