CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicare prescription drug coverage determination request form (INTEGRITY for Duals)

Form and instructions for requesting Medicare Part D coverage determinations, exceptions, prior authorizations, tier exceptions, quantity limit exceptions, and reimbursement requests for Neighborhood Health Plan of Rhode Island members (INTEGRITY for Duals). Applies to requests submitted by members, providers, or authorized representatives.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicare prescription drug coverage determination request form (INTEGRITY for Duals)

Policy CodePolicy N/A

Change TypeMinor / administrative

Effective Date

Next Review Date

Key ActionSubmit prior authorization or exception requests with clinical support including ICD-10 diagnosis, medication history with dates and outcomes, dosing, and a physician rationale (attach CMS-1696 if filed by a representative).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1primary form in document

24/7 Oct-Marcustomer service availability

72h / 24hdecision timeframes

CMS-1696representative form

Coverage Determination Criteria

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Coverage determination criteria

Coverage determinations (exceptions, prior authorizations, tier/step exceptions, quantity limit exceptions, reimbursement, and expedited review) are considered when the physician provides required supporting information. Expedited review is available if waiting 72 hours could seriously harm the member.

General submission requirements: Request must include member and provider information, medication name, dose, route, frequency, start date, expected duration, quantity per 30 days, height/weight, allergies, ICD-10 diagnosis codes for all conditions treated, medication history with dates and outcomes (failure or intolerance), current regimen, and physician rationale when applicable.

If someone other than the member or prescribing physician submits the request, attach representative authorization (CMS-1696) and any supporting clinical documents.

Request types: One of: formulary (formulary/exemption) request, prior authorization, step therapy/tier exception (formulary tier exception), quantity limit exception, tier placement dispute, reimbursement request, or expedited review request.

For formulary or tier exceptions the physician MUST provide a supporting statement documenting trials of preferred/formulary agents, results (failure, intolerance, or contraindication), doses and durations, or rationale for exception.

Supporting clinical detail for formulary/step therapy requests: Physician must document prior medications tested (including dates), outcomes (failure vs intolerance), reasons for adverse effects or contraindications, dose and duration of trials, and any clinical rationale (for example, medical necessity for a different formulation or higher dose, or risk of significant clinical harm if medication changed).

Use the form sections 'HISTÓRICO DE MEDICAÇÃO' and 'FUNDAMENTAÇÃO PARA O PEDIDO' to provide these details.

Expedited review: If the physician certifies that waiting the standard decision timeframe (72 hours) could seriously harm the member's life, health, or ability to regain maximum function, the request may be processed on an expedited basis and decided within 24 hours upon receipt of physician support.72 hours -> 24 hours

Expedited coverage determination cannot be requested for reimbursement of a medication already received.

Expedited coverage determinations (requests for a decision within 24 hours) are reserved for situations where the treating physician certifies that waiting the standard 72-hour timeframe could seriously harm the member’s life, health, or ability to recover. Expedited review cannot be requested for reimbursement of a medication already received.

Provider Submission & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Submit requests for medications that require prior authorization before dispensing. Include member name, DOB, member ID, prescriber name and contact, drug name (including strength, route, quantity per 30 days), start date, duration of therapy, and whether this is a new start or continuation.

Submit via the plan’s designated prior authorization portal or fax number (see payer-specific instructions).
Indicate the type of request: formulary exception, step-therapy override, quantity limit exception, tiering exception, or standard prior authorization.
Provide the prescriber's signature and date where required.

Denial Risk

Missing Clinical Support Risks Denial

Missing or incomplete clinical documentation may lead to partial or full denial of the request or delays in processing. Ensure all relevant clinical information and supportive documentation are attached at time of submission.

Include complete medication history with trialed agents, dates of trials, doses, and outcomes (failure vs intolerance).
Attach relevant diagnoses with ICD-10 codes and supporting clinical notes, labs, imaging, or hospitalization records that substantiate medical necessity.
For requests submitted by a representative, attach documentation of authority (e.g., CMS-1696 or equivalent).

Step Therapy

Step Therapy / Formulary Exception Requirements

Step Therapy / Formulary Exception Requirements: If a requested medication is not on the formulary or is subject to step therapy, the prescriber must document prior trials of preferred agents or provide clinical justification for an exception.

Document all alternative medications tested, including dose, duration, and reason for failure or intolerance.
For tiering exceptions, document why lower‑tier alternatives are medically inappropriate and provide evidence (adverse events, contraindications, or documented lack of efficacy).
If the medication was previously on the formulary but removed, provide history and rationale supporting continued need.

Documentation Required

Required Documentation to Submit

Required Documentation to Submit: Provide a concise but complete clinical package to support coverage determination.

Member demographics and contact information (name, DOB, member ID).
Prescriber information and signature.
Medication details: name, strength, route, quantity per 30 days, frequency, start date, and expected duration.
Diagnosis(es) with corresponding ICD-10 code(s) and pertinent clinical notes.
Complete medication history relevant to the condition, including prior therapies, dates of trials, outcomes, and any adverse reactions.
Laboratory results, imaging, or other objective data that support medical necessity when applicable.
For exceptions or requests by an authorized representative, include documentation of representation (CMS-1696 or equivalent).

Policy Background

This form is the Medicare Part D coverage determination request used to ask for formulary exceptions, tier/step-therapy exceptions, quantity-limit exceptions, prior authorizations, reimbursement requests, or expedited reviews. It collects member and provider demographics, the requested medication and dosing, ICD-10 diagnosis codes, medication history with dates and outcomes, and the physician’s rationale or supporting statement when required.

Requests for formulary or tier exceptions must include a physician’s supporting statement documenting trials of preferred/formulary agents, reasons for failure or intolerance, doses and durations, or other clinical rationale. Prior authorization requests also require clinical support and may need additional information. If a third party submits the request on the member’s behalf, include representative authorization (CMS-1696 or equivalent) and supporting clinical documents.

If the physician certifies that waiting the standard 72-hour decision timeframe could seriously harm the member, an expedited review will be completed within 24 hours when the physician’s supporting statement is provided. If physician support for expedited review is not available, the plan will determine whether the case qualifies for expedited processing.

Representative Authorization & Definitions

Representative authorization (CMS-1696)

DefinitionWritten documentation (CMS-1696 completed or equivalent) required when someone other than the member or the member's physician submits the coverage determination request, attached as proof of representative authority.

When requiredAttach when the requester is not the member or the treating physician; form instructs to complete only the requester section if someone else is filing.

How to obtain helpFor more information about naming a representative, contact the plan or 1-800-Medicare, TTY: 1-877-486-2048, available 24 hours a day, 7 days a week.

Where to attachInclude the completed CMS-1696 (or equivalent written authorization) with the submission as supporting documentation.

Step Therapy / Prior Medication History

Requirement	What to include / evidence
Documentation of prior medication trials (for formulary/step-therapy or tier exceptions)
List medications tried, dates of trials, doses and durations, and outcomes (failure, intolerance, or adverse effects). If not listed elsewhere, specify dose maxima and duration for failed therapies.
Physician supporting statement required for formulary or tier exceptions
A clinical statement from the prescribing physician describing why preferred/formulary agents were ineffective, not tolerated, or contraindicated; include rationale for exception (see note on form).
Documentation of contraindication or adverse reaction to preferred agents
If a preferred or formulary medication is contraindicated or caused adverse effects, list the specific contraindication or adverse reaction for each agent tried.
Stability on current therapy or risk from switching (when applicable)
If the patient is stable on the requested medication, provide a specific explanation of anticipated significant clinical harm from changing therapy (e.g., prior hospitalizations, severe events, loss of function).
Dose/formulation necessity
If requesting a different dosage form or higher dose, specify forms/doses previously tried, results, and medical justification including why alternative dosing strategies are not suitable.
ICD-10 diagnosis code(s)
Provide ICD-10 code(s) for the diagnosis(es) treated with the requested medication.
Medication history and current regimen
Complete medication history with dates, current regimen, and trial outcomes; include supporting clinical documents as needed.
Representative authorization when submitted by third party
Attach CMS-1696 or equivalent written authorization if someone other than the member or prescribing physician submits the request.

Quantity Limit Requests

Quantity request (form field)

Quantity fieldRequester must indicate the quantity requested as 'Quantity per 30 days' on the form (units/tablets/etc.).

Context providedForm captures medication concentration, route, frequency, start date, expected duration, and 'Quantity per 30 days' to justify quantity-limit exceptions.

Supporting documentationWhen quantity limits are an issue, provide medication history including doses tested, dates of trials, and results (failure vs intolerance).

Related request typesQuantity per 30 days information applies to quantity limit exceptions and may be required alongside prior authorization or formulary exception requests.