CurrentCareSourcePolicy N/A

Request for Medicare Drug Coverage Determination (Form and Instructions)

This document is the plan's form and instructions for enrollees, prescribers, or authorized representatives to request Medicare drug coverage determinations, prior authorizations, and formulary exceptions for prescription drugs under the plan.

Policy Summary

PayerCareSource

PolicyRequest for Medicare Drug Coverage Determination (Form)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed form with prescriber signature and required supporting clinical documentation including ICD-10 diagnosis codes and drug history.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24form fields and checklist items (approx.)

24/7phone/TTY contacts listed

24hexpedited decision turnaround if prescriber supports

72hstandard decision timeframe

Coverage Determination Timeframes & Criteria

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Prescriber Requirements & Documentation

Prior Authorization

Prior Authorization Requires Prescriber Supporting Information

Prior authorization requests require the prescriber to provide supporting clinical information to justify the requested drug and expedite review when applicable.

Prescriber must complete the 'Supporting Information for an Exception Request or Prior Authorization' (pages 3–4 of the form).
If expedited review is requested, prescriber must check the REQUEST FOR EXPEDITED REVIEW box and sign to certify that the 72-hour standard review timeframe may seriously jeopardize the enrollee’s life or health.
If the request is not made by the enrollee or prescriber, submit documentation of authority to represent the enrollee (e.g., CMS-1696 or equivalent).

Step Therapy

Formulary / Step Therapy Exception Documentation

Provide full supporting documentation with the exception or step-therapy/formulary exception request so the plan can evaluate medical necessity and tiering/formulary considerations.

Specify whether this is a formulary exception, tiering exception, quantity limit exception, or prior authorization-rule exception.
Include documentation of prior trials of formulary or preferred drugs (see DRUG HISTORY and RATIONALE FOR REQUEST sections) including dates, doses, duration, and outcomes.
When requesting a tiering exception, explain why the lower-cost/tier drug is not appropriate and include trial history or evidence of adverse outcome.

Documentation Required

Supporting Documentation Required

The prescriber must complete detailed clinical fields and include objective supporting information to establish medical necessity.

Prescriber identification: name, office address, phone, fax, signature and date.
Diagnosis and medical information: medication name, strength, route, frequency, date started (or indicate NEW START), expected length of therapy, quantity per 30 days, height/weight, drug allergies, and ICD-10 code(s) for all diagnoses treated.
Drug history: list all drugs tried for the condition with dates, unit dose/total daily dose (if quantity limit issue), results of previous drug trials, and whether failure or intolerance occurred.
Rationale for request: clearly state reasons such as previous adverse outcomes, contraindications to alternatives, medical need for different dosage form or higher dosage, stability on current therapy and risk of harm if changed, with supporting details (drug names, doses, durations, and clinical outcomes).

Documentation Required

Prescriber Supporting Documentation — Rationale & Clinical Detail

Use the RATIONALE FOR REQUEST section to document clinical reasons that alternatives are unsuitable and to summarize prior therapy and outcomes.

If alternatives were tried, list drugs, dates, maximum dose and length of therapy, and results (therapeutic failure vs intolerance) and describe any adverse outcomes.
If alternatives are contraindicated or expected to be less effective, provide a specific clinical explanation why and any supporting evidence.
When requesting exceptions for dosing/formulation or quantity limits, explain why standard dosing or lower-strength options are not appropriate and provide prior trial information.

Purpose & Scope

This form is the plan's official method for requesting Medicare prescription drug coverage determinations, including prior authorizations, formulary exceptions (including tiering and quantity-limit exceptions), and requests for expedited review. It collects enrollee and prescriber information, the name/dosage/quantity of the drug, diagnoses with corresponding ICD‑10 codes, a detailed drug history (previous agents tried, dates, and outcomes), and the prescriber's clinical rationale to support the request.

Prescribers must complete the "Supporting Information for an Exception Request or Prior Authorization" section and provide a signed certification for clinical items such as drug-trial history, reason(s) why alternatives are inappropriate (contraindication, intolerance, or anticipated adverse outcome), current drug regimen, any FDA‑noted contraindications, and monitoring plans for safety concerns. Failure to provide the required supporting clinical information or a prescriber-signed justification may result in delay or denial of the coverage determination.

The form also supports requests for quantity‑limit overrides and tiering exceptions; when quantity limits are at issue the prescriber should list unit dose/total daily dose tried and explain the clinical justification. For formulary or step-therapy exceptions the prescriber must document prior trials of alternate drugs and outcomes or clearly explain why step therapy cannot be met (for example, contraindication or high risk of significant adverse clinical outcome).

If the enrollee or prescriber believes that waiting the standard review time could seriously harm the enrollee, an expedited (fast) decision may be requested. When the prescriber certifies that waiting 72 hours may seriously jeopardize the enrollee's life, health, or ability to regain maximum function, the plan will issue a decision within 24 hours; otherwise the standard decision timeframe is 72 hours.

Key Terms

inv-08: Expedited (fast) decision

DefinitionA request handled within 24 hours when the prescriber certifies that waiting 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function.

When it appliesApplies when the enrollee or prescriber indicates that waiting the standard 72-hour decision timeframe could seriously harm the enrollee; prescriber statement attached triggers automatic 24-hour decision.

How to requestCheck the expedited (fast) decision box on the form and attach the prescriber's supporting statement; signature and date required.

Plan review if prescriber support absentIf prescriber support is not provided, the plan will determine whether the case requires an expedited (fast) decision.

inv-09: Authorized representative

DefinitionA person acting on behalf of the enrollee who must submit documentation of authority (e.g., a completed Authorization of Representation Form CMS-1696 or equivalent) if they are not the enrollee or prescriber.

Required informationRequestor's name, relationship to enrollee, street address, and phone number must be provided on the form.

Documentation to attachAttach Authorization of Representation Form CMS-1696 or equivalent to show authority to represent the enrollee.

Help for appointing a representativeFor more information contact the plan or call 1-800-MEDICARE (1-800-633-4227); TTY users 1-877-486-2048.

Step	Requirement
1
Document prior drug trials and outcomes or provide a specific rationale why step therapy cannot be met (e.g., contraindication, anticipated significant adverse clinical outcome, therapeutic failure). If not recorded in the DRUG HISTORY section, specify drugs tried, dates, results, adverse outcomes, maximum dose and length of therapy where applicable; include explanation why alternative/formulary drugs are contraindicated or would be less effective.

Quantity Limit Exceptions

inv-11: unspecified (form captures quantity limit exceptions)

Captured limitQuantity limits are handled 'as prescribed' on the form; exceptions require prescriber justification when requesting an exception to plan quantity limits.

Required prescriber detailsProvide medication name, strength, route, frequency, date started, expected length of therapy, and quantity per 30 days.

Supporting clinical rationaleDocument drug history, trials and outcomes, adverse reactions, contraindications, or medical need for different/higher dosage to justify quantity exceptions.

Form sections to completeComplete the Diagnosis and Medical Information and RATIONALE FOR REQUEST sections to explain why the quantity limit exception is medically necessary.

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