CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

A member/prescriber form and instructions for requesting a Medicare Part D coverage determination, including formulary exceptions, prior authorization, tiering or quantity-limit exceptions, expedited review requests, and supporting clinical information to be submitted to Optum Rx for BlueCross BlueShield South Carolina Medicare Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Policy CodePolicy N/A

Change TypeInformational form

Effective Date

Next Review Date

Key ActionSubmit the completed form (including prescriber supporting statement for formulary/tiering exceptions) to Optum Rx Prior Authorization Department by mail, fax, phone, or website; include required supporting documentation as noted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this document is an informational form for requesting Medicare Part D coverage determinations.

9Request types listed

24/7Availability Oct 1–Mar 31

8am-8pmStandard phone hours

Request for Medicare Prescription Drug Coverage Determination — Summary

Types of Coverage Determination Requests

Type of Coverage Determination Request (selection list)

Member/prescriber selects one or more request types:

Formulary exception - drug not on formulary: Formulary exception for a drug not on the plan's list of covered drugs (formulary exception).
Formulary exception - drug removed during plan year: Formulary exception because drug was removed from formulary during plan year (formulary exception).
Request prior authorization for the prescribed drug.
Step therapy exception: Exception to requirement to try another drug before receiving the prescribed drug (formulary exception).
Quantity limit exception: Exception to plan's quantity limit so enrollee can receive the prescribed number of pills (formulary exception).
Tiering exception - higher copayment: Tiering exception: plan charges higher copayment than another drug for the condition.
Tiering exception - moved to higher tier: Tiering exception because drug moved to higher copayment tier.
Claim reporting - charged higher copayment: Claim reporting: plan charged higher copayment than it should have.
Reimbursement request - paid out of pocket: Reimbursement request for a covered prescription drug paid out of pocket.

Expedited Decision Request

When to request expedited review:

Expedited Decision Request: Prescriber believes waiting 72 hours could seriously harm life, health, or ability to regain maximum function.;If prescriber indicates harm, decision will be given within 24 hours.;If no prescriber support, plan will decide if expedited is warranted.;Cannot request expedited determination for reimbursement of a drug already received.

Statements reflect conditions and limitation for expedited review; decision timeframe shortens to 24 hours with prescriber support.

Required Supporting Information & Provider Submission Instructions

Supporting information required for formulary/tiering exceptions and prior authorization

Formulary and tiering exceptions require prescriber's supporting statement; prior authorization may require supporting information. Form includes sections for:

Supporting information required

Patient demographics and member ID.
Prescriber information and signature: Prescriber's name, address, phone and signature.
Requested drug details: Requested drug name, strength, quantity per month, route, frequency, expected length of therapy.
Diagnosis and ICD-10 codes: Diagnosis and ICD-10 code(s) for condition(s) being treated.
Detailed drug history: dates of drug trials, results, and whether failures or intolerances occurred.
Clinical rationale for request: Clinical rationale: alternate drugs tried/contraindicated, stability on current drug, medical need for different dosage form/higher dosage, or formulary tier exception rationale.
Safety information and monitoring: Safety information: FDA contraindications, drug interaction concerns, monitoring plan if concerns present.
High-risk elderly assessment: High-risk management for elderly: prescriber assessment whether benefits outweigh risks if age >65.
Opioid-specific information: Opioid-specific fields if requested drug is an opioid: daily MED, other opioid prescribers, medical necessity of MED, whether lower MED would be insufficient.

Prior Authorization

Submit coverage determination or prior authorization request

Submit the completed coverage determination or prior authorization request form to Optum Rx. You can send it by mail (Optum Rx Prior Authorization Department PO Box 2975, Mission, KS 66201), by fax (1-844-403-1028), by phone (1-888-645-6025, TTY 711) or via the plan website (www.scbluesmedadvantage.com). Standard phone availability is 8 a.m.–8 p.m. ET Monday–Friday (extended seven‑day availability Oct 1–Mar 31). Formulary or tiering exceptions require a prescriber’s supporting statement; prior authorization requests may require supporting documentation.

Documentation Required

Attach representation documentation when needed

If the requestor is not the enrollee or the enrollee’s prescriber, attach documentation showing authority to represent the enrollee (a completed Authorization of Representation Form CMS‑1696 or an equivalent written authorization).

Prior Authorization

Expedited review procedure

To ask for an expedited (fast) review, include the prescriber’s supporting statement certifying that waiting 72 hours could seriously harm the enrollee. If the prescriber provides this statement, the plan will give a decision within 24 hours. If no prescriber support is provided, the plan will decide whether an expedited review is warranted. Expedited review is not available for reimbursement requests for drugs already received.

Documentation Required

Provide clinical drug history and rationale

Include a complete clinical drug history and justification: list dates and results of prior drug trials, indicate whether failures or intolerances occurred and explain, state the expected length of therapy, provide the ICD‑10 diagnosis code(s) for the condition(s) being treated, and supply the specific rationale for the exception (for example: contraindication to preferred drugs, patient stability on current therapy, or medical need for a different dosage form or higher dose).

Documentation Required

Safety and monitoring documentation

Document any safety concerns and monitoring plans: indicate whether there are FDA‑noted contraindications or potential drug interactions and explain the issue, discuss benefits versus potential risks, and provide a monitoring plan. For patients over age 65, include the prescriber’s assessment that benefits outweigh risks. If the request is for an opioid, provide the daily cumulative morphine equivalent dose (MED), note whether other opioid prescribers are involved, and state whether the MED is medically necessary or if a lower MED would be insufficient.

OpenPayer

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Request for Medicare Prescription Drug Coverage Determination — Summary

Types of Coverage Determination Requests

Required Supporting Information & Provider Submission Instructions

Definitions

Revision History