Currentharvard pilgrim health carePolicy N/A

Request for Medicare Prescription Drug Coverage Determination (Senior Care Options)

A printable/submitable form and instructions for enrollees or their representatives to request Medicare Part D coverage determinations (formulary exceptions, prior authorizations, tiering/quantity limit exceptions, reimbursement) for Tufts Health Plan Senior Care Options (SCO). It includes required prescriber supporting information, expedited request guidance, contact, submission and interpreter/grievance information.

Policy Summary

Payerharvard pilgrim health care

PolicyRequest for Medicare Prescription Drug Coverage Determination (Senior Care Options)

Policy CodePolicy N/A

Change TypeInformational form/instructions

Effective Date

Next Review Date

Key ActionInclude a prescriber's supporting statement (use the attached form), diagnosis ICD-10 codes, drug history, and rationale when submitting formulary or tiering exception or prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

MultipleCovered/Handled Request Types

24hrExpedited Decision Timeliness

Phone/fax/online/mailSubmission Methods

Policy summary and purpose

This is a printable and submittable form with instructions to request Medicare Part D coverage determinations for Tufts Health Plan Senior Care Options (SCO) enrollees. It covers multiple request types including formulary exceptions (drug not on formulary, drug removed during plan year, step therapy exceptions, quantity limit exceptions), prior authorization, tiering exceptions (to seek lower copayment when plan charges a higher tier), requests about incorrect higher copayments, and reimbursement requests for covered prescriptions paid out-of-pocket.

The form explains required prescriber information and supporting documentation. For formulary and tiering exception requests, the prescriber MUST provide a supporting statement (use the attached 'Supporting Information for an Exception Request or Prior Authorization' form); prior authorization requests may also require supporting information. The prescriber section requests name, contact, signature, diagnosis with ICD-10 codes, medication details (strength, route, frequency, start date, quantity per 30 days), drug history (drugs tried, dates, results, failure vs intolerance), contraindications, drug interaction concerns, high-risk-in-elderly assessment, and opioid-specific information including daily cumulative Morphine Equivalent Dose (MED) when applicable.

The form allows an expedited (fast) decision when waiting the standard 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function. If the prescriber indicates waiting 72 hours could seriously harm the enrollee, the plan will automatically issue a decision within 24 hours. If prescriber support is not provided, the plan will decide whether expedited review is warranted. Expedited coverage determination is not available for reimbursement requests for drugs already received.

Submission and contact information are provided: the form may be mailed or faxed to the Tufts Health Plan Senior Care Options Pharmacy Utilization Management Department or requested by phone at 1-855-670-5934 (TTY: 711); online prior authorization is available at https://point32health.promptpa.com and general website access at tuftsmedicarepreferred.org/sco. The form explains who may make a request (prescriber, enrollee, or an authorized representative) and requires representation documentation (completed Authorization of Representation Form CMS-1696 or written equivalent) when someone other than the enrollee or prescriber submits the request.

Interpreter services, non-discrimination, and grievance contact information are included. Tufts Health Plan provides free interpreter and accessible-format services; contact 1-855-670-5934 (TTY: 711) for language or alternative format assistance. Instructions also provide how to file a grievance or civil rights complaint and list the Tufts Health Plan Civil Rights Coordinator contact details.

Core metadata

PayerHarvard Pilgrim Health Care

Policy titleRequest for Medicare Prescription Drug Coverage Determination (Senior Care Options)

Policy number

Effective date

StatusCURRENT

Handled request typesMultiple request types

Expedited decision timelinessExpedited decisions within 24 hours

Submission methodsPhone / fax / online / mail

Types of coverage determination requests

Types of Coverage Determination Requests

Select the applicable request type:

ANY of the following

I need a drug that is not on the plan's list of covered drugs (formulary exception).
I have been using a drug that was previously included on the plan's list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception).
I request prior authorization for the drug my prescriber has prescribed.
I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (step therapy/formulary exception).
I request an exception to the plan's limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my prescriber prescribed (formulary exception).
My drug plan charges a higher copayment for the drug my prescriber prescribed than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception).
I have been using a drug that was previously included on a lower copayment tier, but is being moved to or was moved to a higher copayment tier (tiering exception).
My drug plan charged me a higher copayment for a drug than it should have.
I want to be reimbursed for a covered prescription drug that I paid for out of pocket.

NOTE: If you are asking for a formulary or tiering exception, your prescriber MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information.

Expedited decision criteria and process

Expedited Decision Criteria

Expedited (fast) decision may be requested when waiting 72 hours could seriously harm the enrollee's life, health, or function:

Prescriber indicates waiting 72 hours could seriously harm the enrollee (automatic 24-hour decision when prescriber supports expedited request).

If prescriber support absent, plan will decide if expedited review warranted.

Expedited coverage determination not available for reimbursement requests for drugs already received.

Prior Authorization

Expedited decision process

If the prescriber indicates that waiting 72 hours could seriously harm the enrollee, the plan will issue a decision within 24 hours. If prescriber support is not provided, the plan will evaluate whether expedited review is warranted. Note: requests for reimbursement for drugs already received are not eligible for expedited review.

Required supporting information and prescriber details

Supporting Information Required

Formulary and tiering exception requests require a prescriber's supporting statement; prior authorization may require supporting information:

Attach prescriber's supporting statement (use attached 'Supporting Information for an Exception Request or Prior Authorization' form) for formulary/tiering exceptions.

Representation documentation required when requester is not enrollee or prescriber (Authorization of Representation Form CMS-1696 or equivalent).

Rationale/Required Details

Prescriber must provide medication, diagnosis (with ICD-10), drug history, contraindications, interactions, high-risk elderly assessment, opioid-specific info (if applicable), and specific rationale choices:

ANY of the following

If alternate drugs tried
- List drugs tried and results of drug trials.
- If adverse outcome, list drug(s) and adverse outcome for each.
- If therapeutic failure, list maximum dose and length of therapy for drugs trialed.
- If contraindication(s), list specific reason why preferred/formulary drugs contraindicated.
If patient stable on current drug(s), provide specific explanation of anticipated significant adverse clinical outcome if medication changed.
If requesting different dosage form or higher dosage, specify dosage forms/doses tried, outcomes, medical reason, and why less frequent dosing with higher strength is not an option.
If requesting formulary tier exception, specify formulary/preferred drugs tried and their outcomes, adverse outcomes if any, therapeutic failure details, or contraindications.
Provide any other explanation as applicable.

Required Explanation (free text field for additional rationale).

Prior Authorization

Prescriber supporting statement required for formulary/tiering exceptions

Formulary and tiering exception requests cannot be processed without a prescriber's supporting statement. Use the attached 'Supporting Information for an Exception Request or Prior Authorization' form and include the diagnosis with ICD-10 code(s), the drug history (drugs tried, dates, results, failures/intolerances), and the clinical rationale for the exception.

Documentation Required

Representation documentation when requester is not enrollee/prescriber

When the requester 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 a written equivalent).

Documentation Required

Opioid-specific documentation

For opioid requests, provide the daily cumulative Morphine Equivalent Dose (MED), indicate whether you are aware of other opioid prescribers for the enrollee (and identify them if so), and justify that the stated daily MED is medically necessary and that a lower total daily MED dose would be insufficient to control the enrollee's pain.

How to submit requests and contact info

Billing Rule

Submission channels and contact

Submit requests by mail or fax to Tufts Health Plan Senior Care Options, Attn: Pharmacy Utilization Management Department (1 Wellness Way, Canton, MA 02021-1166), by phone at 1-855-670-5934 (TTY: 711), or online via tuftsmedicarepreferred.org/sco or https://point32health.promptpa.com for online prior authorization.

This document is a standardized form and instructions for requesting Medicare prescription drug coverage determinations for Tufts Health Plan Senior Care Options enrollees.

Tufts Health Plan states it complies with federal civil rights laws and provides free interpreter services and alternate formats (large print, braille, translated languages). Enrollees needing these services should call 1-855-670-5934 (TTY: 711).

If an enrollee believes the plan failed to provide services or discriminated, the form provides grievance filing information including contacting the Tufts Health Plan Civil Rights Coordinator (address, phone, fax, email) and the option to file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.

Definitions

Formulary exceptionRequest for coverage of a drug not on the plan's formulary, or to override formulary restrictions such as step therapy, quantity limits, or tiering.

Expedited decisionA fast review resulting in a decision within 24 hours when prescriber indicates that waiting 72 hours could seriously harm the enrollee; otherwise plan assesses need for expedited review.