CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicare Part D Coverage Determination and Exception Request Form

Form and instructions for requesting Medicare Part D coverage determinations, exceptions, prior authorizations, tier exceptions, quantity limits, and reimbursements from Neighborhood Health Plan of Rhode Island; intended for members, prescribers, and authorized representatives.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicare Part D Coverage Determination and Exception Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescribers must provide a supporting physician statement, diagnosis with ICD-10 codes, medication history (including trials, doses, durations, and outcomes), and attach CMS-1696 if requester is not the member or prescriber.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24–72Expedited decision hours

1-844-812-6896Member Services

1-855-829-2875Fax for appeals

CMS-1696Representative form

Coverage decision rules

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Coverage decision criteria

Requests for coverage or exceptions are considered when the prescriber provides all required supporting clinical information and documentation.

Formulary/Tier/Quantity Exception: Request is supported by a prescriber statement documenting that preferred/formulary medications were tried and resulted in contraindication, intolerance, or therapeutic failure, or that a higher-tier copayment creates undue burden; include medication trials with doses, durations, and outcomes

Physician statement required; attach supporting documentation and complete HISTORY OF MEDICATIONS and FUNDAMENTAÇÃO sections

Prior Authorization: Include medication details (name, concentration, route, frequency), diagnosis with ICD-10, start date, expected duration, quantity per 30 days, height/weight/allergies, and prior medication trials with outcomes

Provide required clinical information on the MEDICATION and INFORMAÇÕES MÉDICAS sections; prior authorization may require additional supporting information

Expedited Review: If waiting the standard 72 hours could seriously jeopardize the member's life, health, or ability to regain maximum function, the prescriber may request an expedited (24-hour) decision and must provide a physician supporting statement certifying urgency

Check the box for a rapid review and attach the signed physician certification on the form

The form specifies that a rapid (expedited) coverage determination cannot be requested for reimbursement requests for medications already received. Requests for reimbursement of drugs already obtained are excluded from rapid determination consideration and should follow the standard reimbursement submission process.

What the prescriber must provide

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests as indicated on the plan’s drug coverage rules. The prescriber must provide complete clinical information to support the request, including diagnosis(es) with ICD-10 code(s), specific medication name, strength, route, dosing frequency, quantity requested per 30 days, date therapy started (or planned start date for new starts), and expected duration of therapy.

Include member name, DOB, member ID, and prescriber name and contact information.
Specify whether this request is for a formulary exception, tier exception, quantity limit exception, step-therapy override, or standard prior authorization.

Step Therapy

Formulary / Tier / Quantity Exception Requirements

Requests for formulary, tier, or quantity exceptions must include a supporting clinical statement from the prescriber. The statement should explain why formulary alternatives are not appropriate or have failed, or why a tier-lowering is medically necessary. For quantity exceptions, include prior doses tested, dates, and the specific total daily dose or unit dose tested.

For formulary/tier exceptions: list preferred formulary alternatives tried, dates of trials, outcomes (failure, intolerance, contraindication), and reason alternatives are not acceptable.
For quantity exceptions: provide doses tested, treatment duration, and documentation of therapeutic failure or adverse effects at formulary-restricted doses.

Denial Risk

Missing Documentation May Trigger Denial

Missing or incomplete supporting documentation may result in denial or delay of the request. If the physician statement or sufficient clinical information (diagnosis with ICD-10, medication history with dates and outcomes, prescriber contact) is not provided, the review may be closed as inadequate or denied.

Attach relevant clinical records, lab results, and previous medication trial documentation when available.
Provide a signed prescriber statement addressing the clinical rationale when required.

Documentation Required

Required Supporting Documentation

Provide the following supporting documentation with the request to avoid delays: member and prescriber contact information; diagnosis with ICD-10 codes; medication history listing medications tested, dates of trials, and results (failure, intolerance, contraindication) including doses used; current treatment regimen; height/weight and allergies where relevant; and any additional clinical notes or test results that substantiate medical necessity.

Member & prescriber full name and phone number; member ID and DOB.
Diagnosis(es) with corresponding ICD-10 code(s).
Medication history: names, doses, routes, dates tried, and outcomes (failure/intolerance).
Current medication regimen, quantity requested per 30 days, and expected duration of therapy.
Any relevant lab results, clinical notes, or documentation of adverse reactions or contraindications.

Document purpose

This document is the Neighborhood Health Plan of Rhode Island Medicare Part D coverage determination and exception request form. It is used by members, prescribers, or authorized representatives to request access to non‑formulary medications, formulary exceptions (including tier and quantity exceptions), prior authorizations, step‑therapy/tiering exceptions, and reimbursement for covered prescriptions paid out‑of‑pocket.

When requesting a formulary or tier exception, the form requires a physician supporting statement. Prior authorization requests and other managed‑care requirements may also require supporting clinical information; the form provides an attachment titled 'Informações de suporte para um Pedido de exceção ou Autorização prévia' for clinicians to document the necessary medical justification and medication history.

Key definitions

Expedited (urgent) decision — definition and timeframe

DefinitionExpedited (urgent) decision: a request processed within 24 hours when applying the standard 72-hour review period could seriously jeopardize the member's life, health, or ability to regain maximum function; requires the prescriber to certify urgency and provide a supporting statement.

Standard timeframeStandard (non‑expedited) decisions are processed within 72 hours.

Expedited timeframeExpedited (urgent) decisions are processed within 24 hours of the request when urgency is certified.

Who may requestThe prescriber (physician) or member may request expedited review; prescriber certification is required for automatic 24‑hour processing.

Required documentationAttach a physician supporting statement certifying that waiting 72 hours could seriously jeopardize life, health, or recovery; include supporting clinical information per the form (medication history, diagnosis, ICD‑10 codes, etc.).

OpenPayer

Medicare Part D Coverage Determination and Exception Request Form

Coverage decision rules

Required codes and forms

What the prescriber must provide

Document purpose

Key definitions