CurrentFlorida BluePolicy N/A

Request for Medicare Prescription Drug Coverage Determination

This document is a Florida Blue form and instructions for requesting Medicare prescription drug coverage determinations, prior authorizations, formulary/tiering exceptions, quantity limit exceptions, and expedited reviews; it applies to members and their prescribers or authorized representatives seeking coverage decisions.

Policy Summary

PayerFlorida Blue

PolicyRequest for Medicare Prescription Drug Coverage Determination

Policy CodePolicy N/A

Change TypeInformational — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must provide diagnosis, drug history, rationale, and required supporting documentation when submitting prior authorization or formulary/tiering exception requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72/24decision timeframes

24document chunks

1-800-926-6565member phone

1-800-352-2583multilingual hotline

Coverage Determination Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Decision criteria

Requests are evaluated for coverage when specific documentation is provided.

Request types: Formulary exception, tiering exception, prior authorization, quantity limit exception, reimbursement requests, and step-therapy exceptions are all request types available via this form.

See Type of Coverage Determination Request section.

Formulary/tiering exception requirements: Must include a prescriber supporting statement documenting prior trials, contraindications, therapeutic failures, or medical necessity for the requested drug/dosage/formulation.

Formulary and tiering exception requests cannot be processed without a prescriber’s supporting statement (see form instructions).

Prior authorization and supporting information: Prior authorization requests may require supporting clinical information including diagnosis, drug history, dates, outcomes (failure or intolerance), rationale for the request, and dosage/length of trials.

Prescriber may use the attached 'Supporting Information for an Exception Request or Prior Authorization' form.

Step-therapy exception requirements: When requesting an exception to step-therapy, the prescriber must document trials of alternative drugs, outcomes, and reasons alternatives are contraindicated or ineffective, including dates and whether the outcome was failure or intolerance.

Provide specific drug names, trial durations, maximum doses tried, and adverse outcomes as applicable.

Expedited review: If the prescriber certifies that applying the 72-hour standard review timeframe may seriously jeopardize the enrollee’s life or health or ability to regain maximum function, an expedited decision will be made within 24 hours.72 vs 24 hours

Requests for expedited reimbursement cannot be submitted to obtain reimbursement for a drug already received (see exclusions).

You cannot request an expedited coverage determination to obtain reimbursement for a drug you have already received. Expedited (24-hour) decisions are available when the prescriber indicates that waiting the standard 72 hours could seriously harm the enrollee; however, expedited review does not apply to reimbursement requests for drugs already dispensed.

No coverage exclusions are specified within the informational excerpts provided here. The document includes contact and language-assistance information from the U.S. Department of Health and Human Services but does not list any drug-specific coverage exclusions in these sections.

Not applicable in these excerpts. The provided sections are informational (e.g., multilingual and HHS contact details) and do not contain items classified as not medically necessary within the excerpted content.

Prescriber and Provider Requirements

Prior Authorization

Prior Authorization and Formulary Exception Requirements

Prior authorization and formulary/tiering exception requests: Prescribers must provide clinical information to support requests. This includes the diagnosis, drug history, rationale for the request, and specific details when requesting a formulary, tiering, quantity-limit, or step therapy exception. Prior authorization requests may also require supporting clinical information. Formulary and tiering exception requests cannot be processed without a prescriber's supporting statement.

Types of requests: formulary exception, prior authorization, step-therapy exception, quantity-limit exception, tiering exception
Prescriber must include: diagnosis with ICD-10 codes, drug name/strength/quantity, start date, frequency, route, expected length of therapy, height/weight, allergies (chunk 8)
Formulary/tiering exception: prescriber MUST provide a supporting statement (chunk 4, 6)
Prior authorization: may require supporting clinical information (chunk 6)

Documentation Required

Required Supporting Documentation

For any exception or prior authorization request, include required supporting documentation: enrollee demographics and representation documentation if submitted by an authorized representative; prescriber information; full diagnosis(es) with ICD-10 code(s); complete drug history (drugs tried, dates, results, failure vs intolerance); current medication regimen; and a clear clinical rationale explaining contraindications, prior trial results, stability on current therapy, or medical necessity for dose/formulation changes.

If representing the enrollee, attach Authorization of Representation (CMS-1696) or equivalent (chunk 3)
List drugs tried, dates, outcomes, and whether failures were due to intolerance or lack of efficacy (chunk 9)
Provide specific rationale: contraindications, prior adverse outcomes, risk of significant adverse clinical outcome if changed, need for different dosage form or higher dose, or formulary tier justification (chunks 12–13)

Step Therapy

Step Therapy / Formulary Exception Requirements

Step therapy / formulary exception process: When requesting a step therapy or formulary exception, the prescriber must document trials of alternative drugs and the clinical rationale for not using the alternatives (e.g., contraindication, intolerance, therapeutic failure, or risk of significant adverse outcome). Quantity-limit and tiering exception requests must include justification and supporting prescriber statement.

Step therapy exception: document alternative agents tried, duration, maximum dose used, and outcome (chunk 13)
Quantity-limit exception: indicate units/doses and reason for request (chunk 4)
Tiering exception: list formulary/preferred drugs tried and outcomes or contraindications (chunk 13)

Note

No Denial Rules Provided in These Sections

No denial rules are provided in these sections of the source. The materials describe what prescribers must submit and note which requests cannot be processed without supporting statements, but they do not specify denial criteria or appeal timelines here.

This excerpt contains procedural and documentation requirements but does not list grounds for denial or explicit denial rules

Note

Language Assistance Contact and HHS Complaint Information

Language assistance and HHS complaint contacts: Free language assistance services are available in multiple languages. Contact Florida Blue Medicare language services at 1-800-926-6565 (TTY numbers shown) for Spanish and plan-specific assistance. For federal Civil Rights complaints or to file with HHS OCR, see HHS contact information and hotlines listed below.

Florida Blue Medicare language assistance (Spanish): 1-800-926-6565 (TTY: 1-800-955-8770) (chunk 13)
HHS OCR Complaint: 1-800-368-1019; TDD 1-800-537-7697; complaint forms: http://www.hhs.gov/ocr/office/file/index.html (chunk 18)
Additional multilingual language assistance hotlines: 1-800-352-2583 with TTY 1-800-955-8770; FEP: 1-800-333-2227 (chunks 18–20)

Key Definitions

Representative (definition)

DefinitionAn individual authorized to request coverage determinations on behalf of the enrollee; must provide documentation showing authority such as a completed Authorization of Representation Form CMS-1696 or a written equivalent.

Required documentation examplesAttach completed Form CMS-1696 or written equivalent showing authority to represent the enrollee.

When to attachAttach representation documentation when the requester is not the enrollee or the enrollee's prescriber.

Expedited (fast) decision

DefinitionAn expedited (fast) decision is a coverage determination returned within 24 hours when the prescriber indicates that waiting 72 hours for a standard decision could seriously harm the enrollee.

Evidence requiredAttach the prescriber’s supporting statement to the request to indicate need for expedited review; if not provided, the plan will decide whether a fast decision is required.

LimitationYou cannot request an expedited coverage determination solely to obtain reimbursement for a drug you have already received.

TTY (Text Telephone/Teletypewriter)

TermTTY (Text Telephone/Teletypewriter) is the device/service for individuals who are deaf or hard of hearing.

TTY contact infoFor language and accessibility assistance call 1-800-955-8770 (TTY), or use the multilingual hotline 1-800-352-2583 for assistance.

HHS OCR contactHHS OCR main complaint line: 1-800-368-1019; complaint forms available at http://www.hhs.gov/ocr/office/file/index.html.

Step Therapy Exception Requirements

Requirement	Details / Prescriber documentation
Prescriber must document prior drug trials	List drug(s) tried and results of each trial (include dates, outcomes such as therapeutic failure or intolerance, maximum dose used, and length of therapy)
Explain adverse outcomes or contraindications for alternatives	If an alternative produced an adverse outcome (e.g., toxicity, allergy), list the drug(s) and the specific adverse outcome; if an alternative is contraindicated, provide the specific reason why the preferred/formulary drug(s) are contraindicated
Describe stability or high risk with medication change (if applicable)	If patient is stable on current drug and a change would pose high risk, provide a specific explanation of anticipated significant adverse clinical outcome (examples: hospitalization, acute medical visits, heart attack, stroke, falls, marked loss of function, uncontrolled symptoms) and why change would be harmful
Document need for different dosage form or higher dosage (if applicable)	Specify dosage form(s) and/or dose(s) tried and outcomes; explain medical reason for requested form or higher dose and why less frequent dosing or higher strength alternatives are not appropriate

OpenPayer

Request for Medicare Prescription Drug Coverage Determination

Coverage Determination Criteria

Required Diagnosis Coding

Prescriber and Provider Requirements

Policy Background

Key Definitions

Step Therapy Exception Requirements

Quantity Limit Exception Requirements