CurrentCareSourcePolicy N/A

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

A fillable form and instructions for enrollees, prescribers, or authorized representatives to request Medicare prescription drug coverage determinations (formulary exceptions, prior authorizations, tiering exceptions, reimbursement requests, and expedited reviews) from CareSource/Express Scripts.

Policy Summary

PayerCareSource

PolicyREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Policy CodePolicy N/A

Change TypeInformational form

Effective Date

Next Review Date

Key ActionPrescriber MUST provide a supporting statement for formulary and tiering exception requests; include CMS-1696 when a representative submits the request and send submissions via the specified mail, fax, phone, or website channels.

POLICY UPDATE CHANGES

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

1Form Type

MultipleSupported Request Types

Policy overview

This is a fillable request form for Medicare prescription drug coverage determinations from CareSource/Express Scripts for issues such as formulary exceptions, prior authorizations, tiering exceptions, quantity overrides, reimbursement requests, and expedited (urgent) reviews.

Requests may be submitted by the enrollee, the enrollee's prescriber, or an authorized representative (attach Authorization of Representation Form CMS-1696 or equivalent when someone other than the enrollee or prescriber submits).

Types of coverage determination requests

Types of Coverage Determination Requests

Request may be for any ONE of the following:

Formulary exception: request a drug not on the plan's list of covered drugs or removed from the formulary.
Prior authorization request: request prior authorization for the drug prescribed by the prescriber.
Step therapy exception: request an exception to the requirement that another drug be tried first.
Quantity override/formulary exception for quantity: request the number of pills prescribed (quantity exception).
Tiering exception: request a lower copayment because the plan charges higher copayment for the prescribed drug versus another drug that treats the condition.
Reimbursement request: request reimbursement for a covered prescription drug paid for out-of-pocket.

Expedited eligibility, required supporting information, and clinical details

Expedited (Urgent) Decision Eligibility

Expedited review can be requested if waiting 72 hours could seriously harm life/health/function:

Prescriber statement for expedited decision: Prescriber indicates that waiting 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function -> decision within 24 hours will be given automatically.24 hours
Decision timeline: 24 hours if prescriber supports.
Plan assessment of urgency: If no prescriber support for expedited request, the plan will decide if a fast decision is warranted.
Checkbox option and attach statement: Enrollee or prescriber may check box for 24-hour decision and attach supporting prescriber statement.

Supporting Information Requirements

Requests require documentation as specified:

Prescriber supporting statement for formulary and tiering exceptions: Formulary and tiering exception requests require a prescriber's supporting statement.
Cannot be processed without it.
Prior authorization supporting clinical info: Prior authorization requests may require supporting clinical information; prescriber may use attached 'Supporting Information' section.
Representative documentation (CMS-1696): If a representative submits the request, attach documentation of authority (CMS-1696 or equivalent).

Required Clinical Details (to be provided by prescriber)

Prescriber must provide clinical and drug-history details:

Drug name strength quantity: Drug name (include strength and quantity per month if known).
Diagnosis and ICD-10 code(s) for condition(s) being treated.
Start length route frequency quantity: Start date, expected length of therapy, strength, route, frequency, quantity per 30 days.
Drug trial history: Drug history: dates of drug trials and results (failure vs intolerance), including maximum dose and length of therapy.

What prescribers and representatives must do

Documentation Required

Attach prescriber supporting statement for exceptions

Prescriber MUST provide a supporting statement for formulary and tiering exception requests. Prior authorization requests may also require supporting clinical information. Use the attached "Supporting Information for an Exception Request or Prior Authorization" section to provide the prescriber's clinical details.

Use provided Supporting Information section

Documentation Required

Representative authorization required

If someone other than the enrollee or the prescriber submits the request, attach documentation showing authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent).

Authorization of Representation Form CMS-1696 (or written equivalent)

Prior Authorization

Prior authorization submission

Submit prior authorization requests and any supporting information via mail, fax, phone, or the plan website. Mail: Express Scripts, ATTN: Medicare Review, PO Box 66587, St. Louis, MO 63166-6587. Fax: 1-877-251-5896. Phone: 1-833-230-2020 (TTY 711). Website: CareSource.com/Medicare.

Mail: Express Scripts ATTN: Medicare Review PO Box 66587 St. Louis, MO 63166-6587
Fax: 1-877-251-5896
Phone: 1-833-230-2020 (TTY 711)
Website: CareSource.com/Medicare

Documentation Required

Expedited review evidence

For an expedited (urgent) review, include a prescriber's statement that waiting 72 hours could seriously jeopardize the enrollee's life, health, or ability to regain maximum function. If no prescriber support is provided, the plan will evaluate whether a fast decision is warranted.

Definitions & background

Definitions

Expedited (fast) decisionA decision within 24 hours when waiting 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function.

The form includes procedural instructions and fields to request a single coverage determination type (formulary exception, prior authorization, step-therapy/try-first exception, quantity exception, tiering exception, or reimbursement for out-of-pocket payments). It notes that formulary and tiering exception requests require a prescriber's supporting statement and that prior authorization requests may require supporting clinical information; a 'Supporting Information' section is provided for prescribers to complete.

For expedited decisions, the form allows the requester to ask for a fast decision when waiting 72 hours could seriously harm the enrollee; if the prescriber affirms urgency, a decision will be provided within 24 hours, otherwise the plan will determine whether expedited handling is warranted.

Contact and submission channels are provided for sending the completed form and any supporting documentation: mail to Express Scripts (PO Box 66587, St. Louis, MO 63166-6587), fax to 1-877-251-5896, phone at 1-833-230-2020 (TTY: 711), or online at CareSource.com/Medicare.

Policy Summary

PayerCareSource

PolicyREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Policy CodePolicy N/A

Change TypeInformational form

Effective Date

Next Review Date

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