CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Formulario de solicitud de determinación de cobertura de medicamentos de Medicare (Part D)

Formulario en español para solicitar determinaciones de cobertura, excepciones, autorizaciones previas, reembolsos y decisiones sin demora relacionadas con medicamentos recetados del plan Medicare Part D para miembros de INTEGRITY for Duals (HMO D-SNP). Afecta a miembros, proveedores y representantes que presenten solicitudes de cobertura.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFormulario de solicitud de determinación de cobertura de medicamentos de Medicare (Part D)

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionPhysician must provide a supporting statement for formulary or tier exceptions; expedited review available when waiting 72 hours could seriously jeopardize health.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Formulario de determinación de cobertura (en español)

24/7 (Oct–Mar)Horario telefónico

72h / 24hPlazos de decisión

CMS-1696Representación (form)

INTEGRITY for Duals

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.

Coverage request criteria

Types of coverage requests and the specific supporting information required to process each request. Physician documentation is required for certain exceptions; expedited (24-hour) review is available when a physician certifies that the standard 72-hour timeframe could seriously jeopardize the member.

ALL of the following

Request type
- Formulary exception: request for a drug not on the plan's drug list or removal of a previously covered drug; physician statement required; include medication history, prior trials, adverse reactions, contraindications, dosing history.
- Prior authorization: request for prior authorization of a prescribed medication; may require supporting clinical information from the physician; include diagnosis and treatment history.
- Step therapy/Failure of therapy exception: request to waive requirement to try another medication first; physician must provide statement and supporting clinical evidence (treatment history, reasons for failure/intolerance).
- Quantity limit exception: request to exceed the plan's quantity limit (specify amount per 30 days and provide justification; include prior medication trials and dosing).
- Tier (level) exception: request to have a drug covered at a lower copay tier; physician statement required showing medical necessity or adverse reaction to preferred agents.
- Reimbursement request: request for reimbursement for a covered medication paid out-of-pocket by the member; include documentation of payment and prescription.

ALL of the following

Medication details: name, strength, route of administration, frequency, date therapy started, expected duration, quantity per 30 days.
Diagnosis and coding: list all diagnoses treated with the requested medication and provide corresponding ICD-10 codes.
Medication history: prior medications tried for the condition, dates of trials, results (failure vs intolerance) and details of any adverse reactions or contraindications.
Current medication regimen for the condition being treated (if applicable).
Member physical data as applicable: height/weight and allergies to medications.

ALL of the following

Opioid requests: When the requested medication is an opioid, provide the total daily morphine equivalent dose (MED mg/day), list other prescribers, and justify the requested dose.
Quantity-limit specific: If quantity limit is the issue, indicate the dose per unit and the daily total dose tested during prior trials; specify the requested quantity for 30 days.
Dose-change requests: For requests for a different or higher dose, specify prior dosing regimens and outcomes, and explain medical necessity for the higher dose (including why alternative dosing/strengths are not appropriate).

ALL of the following

Authorized representative documentation: If a third party files on behalf of the member, attach CMS-1696 or equivalent documentation of authority.
Submission methods: Requests may be submitted by mail, fax, phone, or online as indicated on the form (include contact details and applicable scheduling).

Diagnosis coding and special reporting

Diagnosis codingICD-10

ICD-10

Diagnosis codes required for conditions treated with requested medication; form requests ICD-10 codes.

Opioid MED reporting (mg/day)

Required opioid dosing metricProvide total daily morphine equivalent dose (MED) in mg/day when an opioid is requested.

Other prescribersIndicate whether other clinicians are prescribing opioids for the member and provide details if yes.

Clinical necessity assessmentConfirm whether the indicated daily MED is necessary (Yes/No).

Titration justificationState whether a lower daily MED would be insufficient to control the member's pain (Yes/No).

Submission, representation, and prior authorization actions

Prior Authorization

Prior authorization / exception support and expedited review

Prior authorization, formulary (formulary/tier) exceptions, and expedited (urgent) reviews require supporting clinical information from the prescribing physician. For formulary or tier exception requests, the physician MUST provide a written supporting statement explaining why the prescribed drug is medically necessary for the member and why an alternative on the formulary is not appropriate. Prior authorization requests may also require clinical documentation to support medical necessity. Expedited (urgent) review requests must include a physician certification that standard review time could seriously jeopardize the member’s life, health, or ability to regain maximum function.

Physician supporting statement is required for formulary/tier exceptions.
Prior authorization requests may require supporting clinical information.
Expedited review: physician must certify that standard 72-hour review could seriously jeopardize life/health or ability to regain function.

Note

Submission methods and representation

You may submit Medicare prescription drug coverage determination requests by mail, fax, phone, or web. If someone other than the member or the member’s physician is submitting on the member’s behalf, that representative must provide documentation of representation (a completed CMS-1696 Authorization to Disclose Personal Health Information or an equivalent written authorization).

Defined terms

Decisión sin demora (Expedited request)

DefinitionA 'Decisión sin demora' (expedited request) is a request marked for review when applying the standard 72-hour review period could seriously jeopardize the member's life, health, or ability to regain maximum function.

Attestation requirementThe requester (typically the clinician) must mark the expedited box and sign to certify the serious jeopardy justification.

Supporting documentationInclude the physician's supporting statement describing the immediate risk; attach any relevant clinical evidence.

Effect on decision timeframesAn approved expedited request results in a decision within 24 hours instead of the standard 72 hours.

Representante (Authorized representative)

Authorized representative definition