CurrentBlue Cross Blue Shield - MassachusettsPolicy N/A

MEDICARE PART D COVERAGE DETERMINATION REQUEST FORM

A prescription form to request Medicare Part D coverage determinations (including exceptions, prior authorization/step therapy exceptions, tiering exceptions, and expedited reviews) for Blue Cross Blue Shield - Massachusetts members; collects prescriber, member, medication, diagnosis, prior therapies, labs, and justification details.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMEDICARE PART D COVERAGE DETERMINATION REQUEST FORM

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must complete all required fields on the form and fax to Clinical Pharmacy at 1-866-463-7700 for processing; call 1-800-366-7778 for questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

3Request Types Covered

24hExpedited Review Timeframe

72hStandard Review Timeframe

Policy overview

This form standardizes submission of Medicare Part D coverage determination requests to Blue Cross Blue Shield - Massachusetts Clinical Pharmacy for exceptions, prior authorization/step therapy exceptions, tiering exceptions, and expedited (24-hour) review requests. It is a prescription form used to request coverage determinations and collects required prescriber, member, medication, diagnosis, prior therapy, lab, and clinical justification details needed to adjudicate coverage. Required fields include member name, member ID, date of birth, prescriber name and NPI, prescriber contact/fax, medication name and strength, quantity requested, route, directions, expected length of therapy, new prescription or date therapy initiated, member diagnosis/ICD-10 code, and prescriber signature/date. The form also gathers prior therapies (drug, strength, dosing, dates, adverse reaction/failure), contraindications to alternatives, relevant lab values (name, value, date), and renewal improvement status. Providers must complete and fax the form to Clinical Pharmacy at 1-866-463-7700 or call 1-800-366-7778 with questions.

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Types of coverage determinations & expedited requests

Types of Coverage Determination Requests

Select all that apply:

Exception Request (Formulary Exception request for non-formulary drug, Quality Care Dosing override for drug with quality care dosing limit)
Exception to Prior Authorization/Step Therapy: Exception to Prior Authorization Request or Step Therapy Requirement (requesting individual consideration for member who does not meet Medical Policy criteria and requires coverage outside Medical Policy guidelines)
Tiering Exception Request (note: not all medications are eligible for tiering exception)

Expedited Review Request

Request for expedited review when standard review time may seriously jeopardize life or health:

Expedited Review Certification: Prescriber checks the expedited review box and signs the form certifying that applying the 72-hour standard review time frame may seriously jeopardize the life or health of the member or the member's ability to regain maximum function

Triggers 24-hour expedited review when certified by prescriber

Form submission & provider requirements

Required Submission Information

Form must include the following fields for processing:

Member name
Member ID
Member date of birth
Prescriber name
Prescriber NPI
Prescriber address/phone/fax: Prescriber address and phone and fax
Medication name and strength: Medication (name and strength)
Quantity requested
Route of administration
Directions for use
Expected length of therapy
New prescription or start date: New prescription OR date therapy initiated
Member diagnosis or ICD-10 code: Member's diagnosis or ICD-10 code
Prescriber's signature and date

Clinical Supporting Information

Optional/required clinical details to support the request:

Previous therapies: drug name, strength, dosing, dates prescribed/stopped, description of adverse reaction or failure
Contraindications to alternatives: Contraindications to alternative therapies: Yes/No and details if Yes
Relevant lab values: lab name, value, date performed (repeatable for multiple labs)
Renewal improvement status: For renewals: has the patient shown improvement while in therapy? Yes/No/NA and description if Yes

Documentation Required

Complete and fax form

Complete all required fields on the Medicare Part D Coverage Determination Request Form and fax the finished form to Clinical Pharmacy at 1-866-463-7700 for processing. For questions, call 1-800-366-7778.

Prior Authorization

Select appropriate request type

Indicate which type of coverage determination is requested (formulary exception, exception to prior authorization/step therapy, or tiering exception). Provide clinical justification and prior therapy history (including drug names, strengths, dosing, dates prescribed/stopped, and description of adverse reaction or failure) to request coverage outside standard policy.

Prior Authorization

Expedited review certification

To request an expedited (24-hour) review, the prescriber must check the expedited review box on the form and sign certifying that applying the 72-hour standard review time frame may seriously jeopardize the member's life, health, or the member's ability to regain maximum function.

OpenPayer

MEDICARE PART D COVERAGE DETERMINATION REQUEST FORM

Policy overview

Types of coverage determinations & expedited requests

Form submission & provider requirements

Who and what this form applies to

Document history