CurrentMVP Health CarePolicy N/A

Request for Medicare Prescription Drug Coverage Determination (Form and Instructions)

This document is a form and instructions for enrollees/prescribers to request Medicare Part D prescription drug coverage determinations, exceptions, prior authorizations, and expedited reviews from MVP Health Care, affecting enrolled members and their prescribers or authorized representatives.

Policy Summary

PayerMVP Health Care

PolicyRequest for Medicare Prescription Drug Coverage Determination (Form and Instructions)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must provide a supporting statement and signature for formulary/tiering exception or prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-800-665-7924phone

1-800-401-0915fax

220 Alexander Stmail

24h/72htimeframes

CMS-1696rep form

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Submission requirements for coverage determination / exceptions

Required submission criteria and rationale

Information and supporting rationale required for coverage determination or exception requests.

Requester must indicate the type of coverage determination requested (e.g., formulary exception, prior authorization, tiering exception, quantity limit exception, reimbursement).

If requesting a formulary or tiering exception, the prescriber MUST provide a supporting statement; prior authorization requests may require supporting information.

See 'Supporting Information for an Exception Request or Prior Authorization' section.

List all diagnoses being treated with the requested drug and provide corresponding ICD-10 code(s).

Include the diagnosis causing any listed symptom, if applicable.

Provide full drug history for the condition(s) requiring the requested drug, including drugs tried, dates of trials, results, and whether prior agents failed or caused intolerance; include current regimen and quantities per 30 days.

ALL of the following

ONE of
- Alternate drug(s) contraindicated or previously tried with adverse outcome — specify drugs tried, results, adverse outcomes, or reasons for contraindication.
- Patient stable on current drug(s) with high risk of significant adverse clinical outcome if medication changed — provide specific explanation of anticipated adverse outcome and supporting clinical history.
- Medical need for a different dosage form and/or higher dosage — specify dosage forms/doses tried, outcomes, and medical reason why alternatives are not acceptable.
- Request for formulary tier exception — document preferred/formulary drugs tried, results, adverse outcomes, or therapeutic failure including maximum dose and duration tried.
- Other explanation — describe specific clinical justification.

Report drug safety concerns: indicate any FDA‑noted contraindications or potential drug interactions; if present, explain the issue, discuss benefits versus risks, and provide a monitoring plan to ensure safety.

If the requested drug is an opioid, provide opioid‑specific information: daily cumulative Morphine Equivalent Dose (MED in mg/day), other prescribers of opioids for the enrollee, and clinical justification for the requested MED.

If an expedited review is requested, the prescriber must certify that applying the 72‑hour standard review timeframe may seriously jeopardize the enrollee's life, health, or ability to regain maximum function; attach the prescriber's supporting statement. Expedited review is not available for retroactive reimbursement requests.

If someone other than the enrollee or prescriber is submitting the request, attach documentation of authority (e.g., CMS‑1696) to represent the enrollee.

The requester/prescriber signature and date are required on the form to complete submission.

Diagnosis and drug-related coding requirements

Diagnosis coding requirementICD-10

ICD-10

Diagnosis and ICD-10 codes must be provided for conditions treated with requested drug.

Opioid MED (mg/day)

Required opioid thresholdDaily cumulative Morphine Equivalent Dose (MED) must be provided in mg/day when requesting an opioid.

Other prescribers disclosureRequest must indicate whether other opioid prescribers exist for the enrollee (Yes/No) and provide explanation if Yes.

Medical necessity for stated MEDRequest must state whether the stated daily MED dose is medically necessary (Yes/No).

Lower-dose insufficiencyRequest must indicate whether a lower total daily MED dose would be insufficient to control the enrollee's pain (Yes/No).

Prescriber and representative responsibilities

Documentation Required

Representation documentation required

If someone other than the enrollee or the enrollee's prescriber submits a request, attach documentation showing the authority to represent the enrollee (for example, a completed Authorization of Representation Form CMS-1696 or a written equivalent). For help appointing a representative, contact the plan or 1-800-Medicare.

Attach completed CMS-1696 or written equivalent.
Include with any coverage determination, formulary/tiering exception, or prior authorization request.

Documentation Required

Prescriber supporting documentation and signature requirement

For formulary or tiering exception requests, the prescriber MUST provide a supporting statement describing the medical rationale for the exception. Prior authorization requests may also require supporting clinical information. Use the "Supporting Information for an Exception Request or Prior Authorization" form when available. Prescriber name, office contact, and signature must be included on supporting documentation.

Required on formulary/tiering exception requests: prescriber supporting statement.
Prior authorization requests: attach supporting clinical information as requested.
Include prescriber name, office phone, and signature.

Prior Authorization

Expedited review process

An expedited (24-hour) decision is available if the prescriber indicates that applying the standard 72-hour timeframe could seriously jeopardize the enrollee's life, health, or ability to regain maximum function. If the prescriber certifies this, the plan will automatically issue a decision within 24 hours. If no prescriber statement is provided, the plan will determine whether the case qualifies for expedited review. Expedited requests are not available for reimbursement requests for drugs already received.

Check the expedited review box and attach prescriber's supporting statement when available.
Plan will provide decision within 24 hours if prescriber certifies harm from a 72-hour wait.
Expedited review not permitted for retrospective reimbursement requests.

Key definitions used in this form

Formulary / Tiering Exception — definition & scope

DefinitionFormulary exception / Tiering exception: a request for a drug not on the plan's list of covered drugs, to address removal or changes in formulary inclusion or tiering, to request a prior authorization alternative, quantity-limit exceptions, or tiering (copayment) exceptions.

Prescriber support requirementIf asking for a formulary or tiering exception, the prescriber MUST provide a supporting statement; prior authorization or other utilization management requests may require supporting information.

Scope of situations coveredIncludes requests when a drug is not on the formulary, was removed during the plan year, to waive step-therapy, to increase quantity limits, or to request a lower copayment (tiering) due to tier movement or higher copayment charge.

Expedited limitationExpedited (24-hour) decisions are available if waiting 72 hours could seriously harm enrollee; expedited requests cannot be used for retrospective reimbursement claims.

Expedited decision — definition & criteria

DefinitionExpedited decision: a faster decision provided within 24 hours when the prescriber indicates that waiting 72 hours for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function.

Who may requestThe enrollee or the prescriber may request an expedited decision; prescriber's supporting statement should be attached when available.

Automatic 24-hour decision with prescriber supportIf the prescriber indicates waiting 72 hours could seriously harm the enrollee, the plan will automatically issue a decision within 24 hours.

Plan discretion without prescriber supportIf no prescriber support is provided, the plan will evaluate whether the case meets criteria for an expedited (fast) decision.

Not applicable to reimbursement requestsExpedited coverage determinations are not available for requests that ask the plan to reimburse for a drug already received (retroactive reimbursement).