CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicare Prescription Drug Coverage Determination / Prior Authorization Request Form

Form and instructions for requesting Medicare Part D coverage determinations, formulary/tiering exceptions, prior authorizations, and expedited reviews for Neighborhood Health Plan of Rhode Island Medicare prescription drug enrollees (Integrity for Duals). Affects enrollees, prescribers, and authorized representatives.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicare Prescription Drug Coverage Determination / Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prescriber-supported clinical information including diagnosis, ICD-10 codes, drug name/strength/quantity, prior trials with dates and outcomes, and attach CMS-1696 if requester is not the enrollee.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursexpedited decision timeframe

72 hoursstandard decision timeframe

1-844-812-6896phone

1-855-829-2875fax

CMS-1696

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

General coverage determination criteria

Covered when ALL of the following are met:

Prescriber documentation: Prescriber must provide a supporting statement for formulary and tiering exceptions; prior authorization requests may require supporting information including diagnosis, drug history (trials, dates, results), and rationale.

see chunks 2,6,10

Previous drug trials: Document trials of preferred or formulary drugs with dates and outcomes, specifying failure versus intolerance or contraindication; include maximum dose and length of therapy for drugs trialed when reporting therapeutic failure.

see chunks 6,10

Drug-specific details: Include medication name, strength, route, frequency, date started, expected length of therapy, and quantity per 30 days; state the enrollee's current drug regimen.

see chunk 6

Rationale for exception or prior authorization: Provide a clinical rationale: alternate drugs contraindicated or previously tried with adverse outcome, risk of significant harm if changed, medical need for different dosage form or higher dose, or other clinical justification as applicable.

see chunk 10

Safety assessment and monitoring: Address FDA contraindications, drug interactions, monitoring plan, and special considerations (e.g., for opioids supply daily cumulative MED); discuss risks and benefits for older adults (>65) as applicable.

see chunks 6,9,10

An expedited coverage determination cannot be requested for reimbursement of drugs that have already been provided to the enrollee (retrospective payment requests). Requests for expedited review apply only when a prescriber indicates that waiting the standard decision timeframe could seriously harm the enrollee; retrospective payment requests are not eligible for expedited treatment.

Required Codes and Clinical Data

Required Codes and FormsICD-10 | Other

ICD-10	Request requires listing all diagnoses being treated with the requested drug and corresponding ICD-10 codes.
CMS-1696	Authorization of Representation form referenced for appointing a representative.

Opioid MED (mg/day) — required

Required opioid detailProvide the daily cumulative Morphine Equivalent Dose (MED) in mg/day for the requested opioid

MED contextIndicate whether the stated daily MED dose is medically necessary (Yes/No)

Alternative prescribersIdentify any other opioid prescribers for the enrollee and explain if present

Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization and Formulary/Tiering Exception Requirements

Prescribers must submit supporting clinical information with all formulary (including tiering) exception requests and may need to provide supporting information for prior authorization requests. Formulary and tiering exception requests CANNOT be processed without a prescriber's supporting statement. Missing required documentation may result in denial or delay.

Attach the completed "Supporting Information for an Exception Request or Prior Authorization" form when submitting a formulary or tiering exception request.
For prior authorization requests, include any documentation requested by the plan; prior auth may also require clinical records or justification.

Step Therapy

Step Therapy (Formulary Exception) Requirements

When requesting a step therapy (formulary) exception, document prior drug trials and the clinical reasons the enrollee cannot use the required step. Include dates, outcomes, and whether the trial failed due to therapeutic failure, intolerance/adverse reaction, or contraindication.

Policy Background

This form is used to request Medicare Part D coverage determinations, including formulary exceptions (coverage for a drug not on the plan’s drug list or to override step-therapy or tiering/quantity limits), tiering exceptions, prior authorizations, quantity limit exceptions, and requests for expedited decisions. It collects enrollee and prescriber information, clinical rationale, prior drug trials and outcomes, diagnoses with ICD-10 codes, drug-specific details (name, strength, route, frequency, quantity per 30 days, and expected length of therapy), and any supporting prescriber statement required for exceptions or expedited review.

Key Definitions

Formulary exception — definition & requirements

DefinitionRequest for coverage of a drug not on the plan's list of covered drugs, or to override step-therapy, quantity limits, or tiering (formulary exception)

Prescriber supporting statementA prescriber's supporting statement is required for formulary or tiering exception requests; use the provided Supporting Information form if needed

Common request typesIncludes requests to: add a non‑covered drug, continue a drug removed during the plan year, override step‑therapy, increase quantity limits, or obtain a lower copayment tier

Expedited decision — when and timeframe

When to requestAsk for an expedited decision if waiting 72 hours for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function

Expedited timeframe

Step Therapy Exception Requirements

Requirement	Details / required documentation
Prescriber supporting statement is required for formulary or tiering exception requests
Per the form: prescriber must provide a statement supporting the request; requests subject to prior authorization may require supporting information. Provider may use the 'Supporting Information for an Exception Request or Prior Authorization' attachment.

Quantity Limit Exception Requirements

Quantity limits — required information

Quantity detail requiredSpecify the requested quantity per 30 days for the drug (quantity per 30 days must be provided)

Exception requestsRequests may seek an exception to the plan's quantity limits; provide drug history and justification when quantity limits are involved

Supporting documentationInclude medication strength, route, frequency, date started, expected length of therapy, and current regimen when requesting an exception to quantity limits