CurrentOscar HealthPolicy N/A

Non-Formulary Marketplace Exception Prior Authorization

Form used to request prior authorization for non-formulary medications (Marketplace HMF) for Oscar Health members; completed by prescribing provider and faxed to CVS/Caremark for review and approval.

Policy Summary

PayerOscar Health

PolicyNon-Formulary Marketplace Exception Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 12, 2014

Next Review DateN/A

Key ActionProvider must complete and sign the Non-Formulary Marketplace Exception form and fax it to CVS/Caremark with required documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 fax numberwhere to send completed forms

1 phone numberCVS/Caremark contact for PA process

6provider attestation questions to determine approval

HIPAA-securefax machine location statement

Coverage Criteria

Authorization criteria

Policy Summary

PayerOscar Health

PolicyNon-Formulary Marketplace Exception Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 12, 2014

Next Review DateN/A

Key ActionProvider must complete and sign the Non-Formulary Marketplace Exception form and fax it to CVS/Caremark with required documentation.

SourceLink

On This Page

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Authorization criteria: 1) The prescribing provider completes and signs the Non-Formulary Marketplace Exception form and submits it to CVS/Caremark by fax;

Fax to 1-855-245-2134; contact CVS/Caremark at 1-855-582-2022 for prior authorization process.

Indication support: 2) The requested drug is for an FDA‑approved indication or an indication supported by recognized compendia/current accepted guidelines (examples: AHFS, Micromedex, current accepted guidelines).

Provider must circle 'Y' on form to indicate compliance and supply supporting documentation as applicable.

Formulary alternative trials (when applicable): 3) If formulary alternatives exist, documentation of failure, intolerance, or contraindication to required number of formulary alternatives is provided (requirement: 3 trials when there are 3 or more alternatives in class; 2 trials when there are 2 alternatives; 1 trial when only 1 alternative exists). Provide medication names, dates of trials, and reasons for failure/intolerance/contraindication.

Provider must answer question 3 on form and supply trial documentation.

When no/formulary alternatives not appropriate

No formulary alternative or alternatives not recommended: 4) If no formulary alternative exists or listed alternatives are not recommended based on published guidelines or clinical literature, provide documentation of the clinical condition supporting use of the non‑formulary agent.
Provider must answer question 4 on form and include clinical documentation.
Specific dosage form required: 5) If a specific non‑formulary dosage form is required (examples: suspension, solution, injection) and not available as a formulary alternative, provide rationale and documentation.
Provider must answer question 5 on form and include rationale/documentation.

Dosing/quantity justification: 6) If the requested quantity or dosing exceeds the initial quantity limit, documentation must show the prescribed quantity/dose falls within manufacturer or compendia dosing guidelines (provide name, quantity, strength, directions, and duration requested).

Provider must answer question 6 on form and include dosing documentation (package insert, AHFS, Micromedex, or accepted guidelines).

Attestation: Provider attests that information on the form is true and accurate by signing and dating the form.

Signature required on submitted form.

Requests that do not include the required supporting documentation or that fail to meet the trial/dosing criteria described on the form may not be approved. The form requires documentation of prior medication trials (names, dates, and reasons for failure/intolerance/contraindication) when formulary alternatives exist, justification when no formulary alternative is appropriate, and dosing details when requested quantity/dosing falls outside initial limits; failure to provide this information implies the request does not meet the stated criteria.

Coding

Diagnosis Codes (provider-entered)ICD-10

ICD Code

Requested diagnosis code — provider to supply

Number of formulary alternatives to trial — mapping

Rule for classes with 3 or more formulary alternativesIf a therapeutic class has 3 or more formulary alternatives, the provider must document trials of 3 formulary alternatives (3 -> 3 trials).

Rule for classes with 2 formulary alternativesIf a therapeutic class has 2 formulary alternatives, the provider must document trials of 2 formulary alternatives (2 -> 2 trials).

Rule for classes with 1 formulary alternativeIf a therapeutic class has only 1 formulary alternative, the provider must document a trial of that single formulary alternative (1 -> 1 trial).

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Submission

Provider must complete and sign the Non-Formulary Marketplace Exception prior authorization form and fax it to CVS/Caremark for review at 1-855-245-2134. For questions about the prior authorization process, contact CVS/Caremark at 1-855-582-2022.

Fax signed Non-Formulary Marketplace Exception form to CVS/Caremark: 1-855-245-2134
Questions about prior authorization: CVS/Caremark 1-855-582-2022

Step Therapy

Step therapy / Formulary Alternative Trials

If formulary alternatives exist, document failure, intolerance, or contraindication for required number of alternatives based on class size. Include medication names, dates of trials, and reasons for failure/intolerance/contraindication. The requirement is: 3 alternatives tried for a class with 3+ alternatives; 2 alternatives for a class with 2 alternatives; 1 alternative if only 1 exists.

List each formulary alternative tried with start/end dates
Provide clinical reason for failure, intolerance, or contraindication for each
State class size and number of required trials

Documentation Required

Required Supporting Documentation

Provide required supporting documentation to justify the non-formulary request. Documentation must include prior medication trials (name of medication(s), dates of trial(s), and reason for treatment failure(s), intolerance and/or contraindication), the clinical condition when no formulary alternative is appropriate, or the specific dosage form needed that is not available in formulary alternatives. For dosing exceptions, include medication name, quantity, strength, directions, and duration requested and confirm prescribed quantity falls within manufacturer's or compendia dosing guidelines.

Medication name(s), trial dates, and documented reason(s) for failure/intolerance/contraindication
Description of clinical condition if no formulary alternative is appropriate
Specification of required dosage form (e.g., suspension, solution, injection) if applicable
Dosing justification: name, quantity, strength, directions, duration, and source of dosing guideline (manufacturer insert, AHFS, Micromedex, guidelines)

Denial Risk

Documentation-related Denials

Failure to provide required documentation or dosing justification may result in denial of the non-formulary exception request. Ensure the prescriber (or authorized representative) signs and dates the form.

Unsigned or undated forms risk denial
Incomplete medication trial details or missing reasons for failure/intolerance/contraindication may lead to denial
Missing dosing documentation for quantity exceptions may lead to denial

Step	Requirement
1
Number of required trials equals number of formulary alternatives in the therapeutic class as specified on the form: 3 alternatives = 3 trials; 2 alternatives = 2 trials; 1 alternative = 1 trial. Documentation of medications tried, dates, and reason for failure/intolerance/contraindication is required for approval.

Definitions

Formulary alternative trials — definition and documentation requirements

Definition of formulary alternative trialsDocumented trials of preferred agents in the same therapeutic class used to justify a non‑formulary exception request; documentation must include medication name(s), dates of trial(s), and reason(s) for inadequate response, intolerance, or contraindication.

When trials are requiredTrials are required when the patient is unable to take preferred formulary alternatives due to inadequate response, intolerance, or contraindication; the required number of trials depends on number of alternatives in the class (see mapping).

What to document for each trialFor each formulary alternative tried, provide the medication name, dates of the trial, and the reason for treatment failure, intolerance, or contraindication.

Exceptions based on guidelines or lack of alternativesIf no formulary alternative exists or listed alternatives are not recommended per published guidelines, provide documentation of the clinical condition explaining why alternatives are not appropriate.

Background

The Non-Formulary Marketplace Exception form is used by the prescribing provider to request prior authorization for a non-formulary medication when a member may need an exception due to lack of efficacy, intolerance, contraindication, a required dosage form not available on formulary, or when dosing/quantity requested is outside standard limits. The provider must complete and sign the form, attest to the screening questions about indication, formulary alternative trials, clinical justification, dosage form needs, and dosing conformity with manufacturer or compendia guidelines, and fax the signed form to CVS/Caremark for review at the number provided.

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