CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Request for Medicare Prescription Drug Coverage Determination

This form and policy govern how enrollees (or their authorized representatives/prescribers) request Medicare Part D coverage determinations, exceptions, prior authorizations, tiering or quantity limit exceptions, and expedited reviews for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRequest for Medicare Prescription Drug Coverage Determination

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber may submit a coverage determination, formulary/tiering exception, prior authorization, quantity limit exception, or expedited review request and must attach supporting documentation when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-844-812-6896Phone number to request determinations

1-855-829-2875Fax number for submissions

WWW.Lnhpri.org/DualCONNECTWebsite for online requests

CMS-1696Authorization form referenced

TTY 711

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Coverage determination requirements and exceptions

Required information and documentation for coverage determinations

Covered when ALL of the following administrative and clinical items are provided with the request; additional supporting documentation may be required for certain exception types.

ALL of the following

If requester is not the enrollee, attach Authorization of Representation (e.g., CMS-1696)
Prescriber name, address, office phone, fax, signature and date

ALL of the following

ONE of
- Formulary exception (drug not on formulary, removed from formulary, or moved tiers)
- Tiering exception (request lower copayment)
- Prior authorization
- Quantity limit exception
- Reimbursement request

ALL of the following

Medication details: name, strength, route, frequency, date started, expected length of therapy, quantity per 30 days
Diagnosis and ICD-10 code(s) for condition(s) treated with the requested drug
Drug history for the condition: drugs tried, dates of trials, results (failure vs intolerance)
Rationale for request: alternate drugs tried/contraindicated, details of prior adverse outcomes or therapeutic failures, and clinical justification for medical necessity

ALL of the following

Formulary and tiering exceptions: MUST include a prescriber supporting statement (use Supporting Information for an Exception Request or Prior Authorization form)
Prior authorization: may require additional supporting clinical information as indicated
Quantity limit exception: provide quantity per 30 days and explain need for exception

Expedited review

Grant expedited (24-hour) review when the expedited criteria are met; evidentiary expectations are described below.

ALL of the following

Prescriber indicates that waiting 72 hours for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function
PLAN ACTION
- If prescriber provides supporting statement, plan will automatically provide a decision within 24 hours
- If no prescriber statement is provided, the plan will review submitted information and decide whether expedited review is warranted

ALL of the following

Attach prescriber supporting statement certifying that a 72-hour wait may seriously jeopardize life, health, or ability to regain maximum function (use the expedited request checkbox and supporting statement field)

Drug safety and high-risk management

Safety considerations and additional information required for high‑risk drugs and special populations.

ALL of the following

Report any FDA‑noted contraindications to the requested drug and whether there is concern for a drug interaction with the enrollee's current regimen
If contraindications or interactions exist, explain the issue, discuss benefits versus potential risks, and provide a monitoring plan to ensure safety

ALL of the following

If enrollee is >65 years, prescriber must state whether benefits of treatment outweigh potential risks in this elderly patient (YES/NO)

ALL of the following

For opioid requests, provide the daily cumulative Morphine Equivalent Dose (MED) in mg/day

Coding and quantity information

Diagnosis coding requirementICD-10

ICD-10

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

Quantity per 30 days

Quantity per 30 daysProvide the specific quantity per 30 days for the requested medication as part of the clinical information (field labeled 'Quantity per 30 days').

When to request a quantity limit exceptionRequest a quantity limit exception when the plan's limit on the number of pills or units would prevent the member from receiving the number prescribed by the prescriber (refer to 'quantity limit' language in request types).

Supporting documentation for exceptionsIf quantity limit is an issue, include drug history with drugs tried, dates, results, and whether prior trials were failures or due to intolerance; explain the unit dose/total daily dose tried as applicable.

New start vs ongoing therapySpecify whether the request is for a new start and include date started and expected length of therapy to justify the requested quantity per 30 days.

Prescriber role and signaturePrescriber must provide supporting statement when requesting exceptions; include prescriber name, contact information and signature on supporting information form.

How providers request determinations and expedite decisions

Documentation Required

How to submit requests and required documentation

How to request a coverage determination (prior authorization, formulary/tiering exception, quantity limit exception, or reimbursement for an out‑of‑pocket payment): Submit a completed request including the member information, drug name, strength, requested quantity/days’ supply, diagnosis, and reason for the request. If the request is for a formulary or tiering exception, the prescriber must include a supporting statement explaining the medical necessity and why alternatives are not appropriate. For prior authorization requests, include any clinical documentation that supports the medical necessity (e.g., chart notes, prior treatment failures, lab results). Attach copies of relevant records when available.

Submission channels: fax or electronic submission per payer instructions; include completed request form and any supporting documentation.
Form requirements: member name, date of birth/ID, prescriber name/NPI, medication name/strength/route, diagnosis, length of therapy requested, and prescriber signature.
Supporting documentation: clinical notes, prior treatment history, lab results, and the completed 'Supporting Information for an Exception Request or Prior Authorization' form when applicable.

Key definitions

Formulary exception

DefinitionFormulary exception is a request when a drug is not on the plan's formulary, was removed from the formulary during the plan year, or is subject to a utilization requirement (e.g., prior authorization or step therapy).

When to useUse a formulary exception when the member needs a drug not covered by the plan, when a previously covered drug has been removed, or to avoid requirements such as required trials of alternative drugs.

Prescriber supporting information requiredFormulary exception requests cannot be processed without a prescriber's supporting statement; prescribers may use the provided 'Supporting Information for an Exception Request or Prior Authorization' form.

Additional documentationInclude clinical rationale, diagnosis with ICD-10 codes, drug history (drugs tried, dates, results), and any relevant monitoring or safety information to support medical necessity.

Tiering exception

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRequest for Medicare Prescription Drug Coverage Determination

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Include the same clinical and administrative documentation required for standard requests (medication details, diagnosis with ICD-10 code(s), drug history, rationale) to support the urgency

ALL of the following

Expedited coverage determinations are not available for reimbursement requests for drugs already received (retrospective reimbursement)

Disclose whether there are other opioid prescribers for this enrollee and provide details if yes

State whether the documented daily MED dose is medically necessary and whether a lower total daily MED dose would be insufficient to control the enrollee's pain

Prior Authorization

Expedited decision process

If the prescriber states that waiting 72 hours for a standard decision could seriously jeopardize the member’s life, health, or ability to regain maximum function, the request will be handled as an expedited (fast) decision and a determination will be issued within 24 hours. If the prescriber provides a supporting statement attesting to the medical urgency, attach it to the request; checking the expedited review box and the prescriber’s supporting statement will automatically trigger expedited handling. If no prescriber statement is provided, the plan will determine whether the situation warrants expedited review. Expedited review is not available for requests solely seeking reimbursement for drugs already paid for out of pocket.

Timing: standard decision timeframe is 72 hours; expedited decision timeframe is 24 hours from receipt of the request when expedited criteria met.
Prescriber attestation: attach the prescriber’s supporting statement or check the expedited box on the form to certify urgency.
Limitations: expedited review cannot be used for reimbursement requests for drugs already received.

DefinitionTiering exception is a request asking the plan to charge the lower copayment when the plan places the prescribed drug on a higher copayment tier than another drug that treats the same condition.

When to requestRequest a tiering exception when the plan charges a higher copayment for the prescribed drug than for another therapeutically equivalent drug, or when a drug has been moved to a higher copayment tier during the plan year.

Required prescriber supportTiering exception requests require a prescriber's supporting statement; include clinical rationale showing why the lower-tier alternative is not appropriate for the member.

Expedited decision

DefinitionAn expedited decision is a faster (24-hour) coverage determination granted when waiting the standard 72-hour timeframe could seriously harm the enrollee's life, health, or ability to regain maximum function.

How expedited is grantedIf the prescriber indicates that a 72-hour wait could seriously harm the enrollee, the plan will automatically provide a decision within 24 hours upon receipt of the prescriber's statement.

When prescriber statement not providedIf no prescriber statement is provided, the plan will independently determine whether the case meets criteria for an expedited (24-hour) review.

LimitationsAn expedited coverage determination cannot be requested for reimbursement of drugs already obtained and paid for by the enrollee (retrospective reimbursement requests).