CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

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

This document is the Neighborhood Health Plan of Rhode Island form and instructions for requesting Medicare prescription drug coverage determinations (formulary exceptions, prior authorizations, tiering/quantity exceptions, reimbursement) and explains who may file, required supporting information, and expedited decision criteria. It affects Medicare Part D enrollees and their prescribers or authorized representatives.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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 ActionSubmit the completed coverage determination form with prescriber supporting statement (and CMS-1696 if represented) to request formulary exceptions, prior authorization, tiering or quantity limit exceptions, or reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-855-829-2875Fax number for submissions

1-844-812-6896Phone / Member Services

TTY 711TTY

24 hr / 72 hrReview timeframes

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 Determination Criteria

Criteria and required supporting information to request coverage determinations, exceptions, or prior authorization:

ALL of the following

ONE of
- Formulary exception (drug not on plan or removed from formulary) or exception to step-therapy or quantity limit; prescriber MUST provide a supporting statement for formulary/tiering exceptions
- Prior authorization request for the prescribed drug; may require supporting clinical information
- Tiering exception (request to move drug to lower cost tier) or reimbursement request for a covered drug paid out-of-pocket

ALL of the following

Prescriber statement attached for formulary or tiering exceptions (required)
For prior authorization, attach clinical information as requested (drug history, diagnoses with ICD-10 codes, prior drug trials and outcomes, contraindications, and rationale)
If requesting a quantity limit exception, specify quantity per 30 days and document unit dose/total daily dose tried if relevant

Expedited review option: Requester may check request for expedited review if prescriber certifies that applying the 72-hour standard timeframe may seriously jeopardize the enrollee's life, health, or ability to regain maximum function; expedited requests trigger 24-hour decision timelines

ALL of the following

Form includes enrollee contact information and prescriber signature block; medication details (name, strength, route, frequency, date started, expected length of therapy) and ICD-10 diagnosis codes must be provided
If someone other than the enrollee or prescriber submits the request, documentation of authority (e.g., CMS-1696 or equivalent) must be provided

ALL of the following

Report drug allergies, contraindications, potential interactions, and monitoring plan or benefit-versus-risk explanation as part of the rationale

Actions Supported by the Request Form

Prior Authorization

Coverage Determination Request Actions

Use this form to request coverage determination actions related to prescription drugs. The form supports formulary exceptions, prior authorization requests, tiering exceptions, quantity limit exceptions, reimbursement requests for drugs paid out-of-pocket, and requests related to drugs moved between formulary tiers. If you are requesting a formulary or tiering exception, the prescriber MUST include a supporting statement. Prior authorization or other utilization management requests may also require supporting clinical information. Attach any relevant supporting documents (medical records, prior drug trial documentation, lab results, etc.).

Formulary exception for a drug not on the plan's formulary
Formulary exception for a drug being removed from the formulary during the plan year
Prior authorization request for a prescribed drug
Exception to step-therapy (requirement to try another drug first)
Exception to quantity limits to obtain the prescribed number of units
Tiering exception to seek a lower copayment for the prescribed drug
Tiering exception for a drug moved to a higher copayment tier
Dispute of an incorrect higher copayment charged by the plan
Request for reimbursement of an out-of-pocket payment for a covered prescription

Documentation Required

Supporting Documentation Required

If requesting a formulary or tiering exception, the prescriber's statement is required and should explain the medical necessity of the requested drug compared to alternatives. For prior authorization or other utilization management requests, include documentation of prior drug trials, dates, and reasons for failure or intolerance. For quantity limit exceptions, list the unit dose and total daily dose tried and the quantity needed per 30 days. For expedited review requests, the requester must certify that applying the standard review timeframe may seriously jeopardize the enrollee's life, health, or ability to regain maximum function.

Attach prescriber's supporting statement for formulary or tiering exceptions
Include drug history: drugs tried, dates, and results (failure vs intolerance)
Specify quantity per 30 days and unit/total daily dose when quantity limit is the issue
For expedited review, check the expedited box and provide certifying signature

Key Definitions

Formulary / Tiering Exception

DefinitionFormulary/Tiering Exception: A request when a drug is not on the plan's list of covered drugs, has been removed from the formulary, requires a step therapy exception, or when the drug has been moved to a higher copayment tier and the enrollee requests lower tier cost-sharing.

Prescriber requirementFormulary and tiering exception requests cannot be processed without a prescriber's supporting statement; prescriber may use the 'Supporting Information for an Exception Request or Prior Authorization' form to provide this information.

When to useUse for: non‑covered drugs, drugs removed during the plan year, step therapy exceptions, quantity limit exceptions, and tiering (copayment) exceptions.

Expedited (Fast) Decision

DefinitionExpedited decision: a request for a fast decision when waiting the standard 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function.

TimeframeIf prescriber indicates waiting 72 hours could seriously harm health, plan will automatically issue a decision within 24 hours; otherwise the plan will decide if expedited review is warranted.

How to requestCheck the expedited review box on the form and attach a supporting statement from the prescriber; sign and date the certification for expedited review as indicated on the form.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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

SourceLink

On This Page

OpenPayer

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

Coverage Determination Criteria

Diagnosis and Quantity Fields

Actions Supported by the Request Form

Key Definitions