CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Form and instructions for enrollees, prescribers, or authorized representatives to request Medicare prescription drug coverage determinations (formulary exceptions, prior authorizations, tiering/quantity-limit exceptions, reimbursement claims, expedited reviews) from Blue Cross Blue Shield - South Carolina via Optum Rx.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must provide a supporting statement for formulary and tiering exceptions and supporting clinical information for prior authorization using the attached Supporting Information form and include diagnoses, ICD-10 codes, prior drug trials with dates and outcomes, allergies, and monitoring plans.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported in this brief.

8Request types covered by the form

24Expedited decision hours

72Standard decision timeframe (hours)

Policy summary

This is the Standard Medicare Part D coverage determination form used by Blue Cross Blue Shield - South Carolina via Optum Rx to request coverage determinations for prescription drugs.

The form covers multiple request types including formulary exceptions (for drugs not on the plan list or drugs removed from the formulary), prior authorizations, tiering and quantity‑limit exceptions, and reimbursement requests for covered drugs paid for out‑of‑pocket.

PayerBlue Cross Blue Shield - South Carolina

PolicyREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Policy NumberN/A

Effective Date

StatusCURRENT

Scope summaryForm and instructions for enrollees, prescribers, or authorized representatives to request Medicare prescription drug coverage determinations (formulary exceptions, prior authorizations, tiering/quantity-limit exceptions, reimbursement claims, expedited reviews) from Blue Cross Blue Shield - South Carolina via Optum Rx.

Types of coverage determinations & expedited eligibility

Types of Coverage Determination Requests

Select one or more request types for the coverage determination:

Formulary exception: need a drug that is not on the plan's list of covered drugs
Formulary exception: have been using a drug previously on the plan's list that is being removed
Prior authorization: request prior authorization for the prescribed drug
Formulary exception: exception to step therapy (requirement to try another drug before the prescribed drug)
Formulary exception: exception to plan's quantity limit to receive the number of pills prescribed
Tiering exception: request lower copayment because plan charges higher copayment than for another drug treating the condition
Tiering exception: drug moved to a higher copayment tier during plan year
Reimbursement request: want to be reimbursed for a covered prescription drug already paid for out-of-pocket

Expedited Decision Eligibility

Criteria for expedited (24-hour) review:

Prescriber indicates that waiting 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function
If prescriber provides supporting statement, decision will be given within 24 hours
If no prescriber support provided, plan will decide if expedited review is warranted
Expedited coverage determination is NOT available for reimbursement requests for drugs already received

Required actions and submission instructions

Documentation Required

Prescriber supporting statement required

For formulary and tiering exception requests (and for prior authorization requests as indicated), the prescriber must provide a supporting statement using the attached form that summarizes the clinical rationale. Required clinical elements include all relevant diagnoses with ICD-10 codes, dates and results of prior drug trials (failure vs intolerance), allergies, and a monitoring plan (including benefits vs risks if contraindications or interactions exist).

Diagnoses being treated with corresponding ICD-10 codes
Dates and results of prior drug trials (failure vs intolerance) with outcomes
Allergies (drug allergies) and other relevant diagnoses
Monitoring plan and discussion of benefits vs risks for contraindications or interactions
Expected length of therapy and current medication regimen (if applicable)

Prior Authorization

Prior authorization submission

Submit prior authorization requests and required supporting information to the Optum Rx Prior Authorization Department using one of the contact methods below; availability is Monday–Friday 8 a.m.–8 p.m. ET (October 1–March 31 seven days/week 8 a.m.–8 p.m. ET).

Mail: Optum Rx Prior Authorization Department, PO Box 2975, Mission, KS 66201
Fax: 1-844-403-1028
Phone: 1-888-645-6025 (TTY 711)
Website: WWW.scbluesmedadvantage com
Availability: Mon–Fri 8am–8pm ET; Oct 1–Mar 31 seven days/week 8am–8pm ET

Documentation Required

Representative authorization

If the person submitting the request is not the enrollee or the prescriber, attach a completed Authorization of Representation Form CMS-1696 or equivalent documentation demonstrating authority to act on the enrollee's behalf.

Denial Risk

Expedited request without prescriber support may be denied

If a prescriber does not provide support for an expedited request, the plan will decide whether expedited review is warranted; note that reimbursement-only requests for drugs already received are not eligible for expedited coverage determinations.

Supporting documentation required includes a prescriber supporting statement for formulary and tiering exceptions and clinical information for prior authorization requests; if someone other than the enrollee or prescriber submits the request, attach an Authorization of Representation (Form CMS‑1696) or equivalent.

Key data elements to attach or complete are the drug name with strength and quantity per 30 days, diagnosis with ICD‑10 code(s), dates and results of prior drug trials (failure vs intolerance), current drug regimen, and the expected length of therapy.

If the requested drug has FDA contraindications or potential interactions, explain the issue, discuss benefits vs potential risks, and provide a monitoring plan to ensure safety.

For enrollees over age 65, the prescriber must state that the benefits outweigh the potential risks for elderly patients.

If the requested drug is an opioid, provide the daily Morphine Equivalent Dose (MED), list other opioid prescribers, and answer whether the stated MED is medically necessary and whether a lower MED would be insufficient.

Supporting information & definitions

Supporting Information Requirements

Information required to process requests:

Prescriber supporting statement required for formulary and tiering exception requests
Prior authorization requests require supporting clinical information
Attach documentation showing authority to represent enrollee if requester is not enrollee or prescriber (Authorization of Representation Form CMS-1696 or equivalent)
Provide drug name, strength, quantity per month, diagnosis and ICD-10 codes, dates and results of prior drug trials (failure vs intolerance), expected length of therapy, allergies, and other relevant diagnoses
If drug has FDA contraindications or potential interactions, explain issue, benefits vs risks, and monitoring plan
If enrollee >65 years, prescriber must state benefits outweigh risks for elderly
If requested drug is opioid, provide daily Morphine Equivalent Dose (MED), list other opioid prescribers, and answer necessity questions regarding MED

The form includes fields for enrollee information (name, DOB, address, member ID), requester details if different from the enrollee, prescriber information and signature, diagnosis and medical information (including ICD‑10 codes, expected length of therapy, allergies), detailed drug history with dates and outcomes of prior trials, and sections for drug safety concerns and rationale for the request.

Expedited decisionA faster review (decision within 24 hours when prescriber indicates waiting 72 hours could seriously harm the enrollee).

Formulary exceptionRequest to cover a drug not on the plan's list of covered drugs, or to continue coverage of a drug removed from formulary.

Tiering exceptionRequest to pay a lower copayment because the prescribed drug would otherwise be placed on a higher cost-sharing tier.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Policy summary

Types of coverage determinations & expedited eligibility

Required actions and submission instructions

Supporting information & definitions

Revision history