Currentpriority healthPolicy N/A

Request for Medicare Prescription Drug Coverage Determination

This document is a Priority Health form for enrollees, prescribers, or authorized representatives to request Medicare prescription drug coverage determinations (including prior authorization, formulary exceptions, tiering exceptions, quantity limits, expedited reviews, and reimbursement requests). It affects Priority Health Medicare plan members and their prescribers/representatives.

Policy Summary

Payerpriority health

PolicyRequest for Medicare Prescription Drug Coverage Determination

Policy CodePolicy N/A

Change TypeAdministrative form — no material changes

Effective Date12062011

Next Review DateN/A

Key ActionPrescriber may submit coverage determination requests and must provide a supporting statement for formulary or tiering exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursexpedited decision timeframe

72 hoursstandard decision timeframe

1submission address/fax provided

800 466-6642phone

Information Needed for Coverage Determinations

Required information and decision timelines

Information and clinical rationale required to support a coverage determination request:

Required form fields

Enrollee Information (identify member) - include any supporting documents as applicable.
Prescriber Information and Signature (prescriber must sign; prescriber statement is REQUIRED for formulary or tiering exceptions and may be required for prior authorization).
Medication Details: Medication name, strength and route of administration, frequency, quantity, new prescription OR date therapy initiated, expected length of therapy, height/weight, drug allergies, and diagnosis.

Type of coverage determination requested (check applicable)

Policy Summary

Payerpriority health

PolicyRequest for Medicare Prescription Drug Coverage Determination

Policy CodePolicy N/A

Change TypeAdministrative form — no material changes

Effective Date12062011

Next Review DateN/A

Key ActionPrescriber may submit coverage determination requests and must provide a supporting statement for formulary or tiering exceptions.

SourceLink

On This Page

Clinical rationale required for formulary/tiering exceptions and prior authorization

Alternate drug(s) contraindicated or previously tried but with adverse outcome (specify drug(s) tried or contraindicated, adverse outcome for each, and if therapeutic failure the length of therapy on each).
Patient is stable on current drug(s) with high risk of significant adverse clinical outcome if medication is changed (specify anticipated adverse clinical outcome).
Medical need for different dosage form and/or higher dosage (specify dosage forms/dosages tried and medical reason).
Request for formulary tier exception: document that formulary/preferred drugs are contraindicated or tried and failed, or were not as effective (include length of therapy and outcomes for drugs tried).
Other clinical justification (provide required explanation and supporting details).

How to Request and Submission Requirements

Note

inv-03: How to submit and who may request

Use this form to request one of the coverage determination types listed below. Your prescriber may submit the request on your behalf. If someone else will request on your behalf, they must be your authorized representative.

Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

Prior Authorization

inv-04: Types of coverage determination requests

Select the specific type of coverage determination you are requesting. For formulary or tiering exceptions, your prescriber MUST provide a supporting statement. Prior authorization requests and other utilization management requests may also require additional supporting information.

Formulary exception — request a drug not on the plan's formulary.
Formulary exception for a drug removed during the plan year — request continued coverage for a drug previously covered but removed.
Prior authorization — request prior authorization for the drug prescribed by your prescriber.
Step-therapy (formulary) exception — request an exception to the requirement to try another drug first.
Quantity limit exception — request an exception to the plan's pill/quantity limits to receive the prescribed amount.
Tiering exception — request a lower copayment when a higher-tier drug is prescribed instead of a lower-tier alternative.
Tiering exception for a drug moved to a higher copay tier during the plan year — request relief from a mid-year tier increase.
Coverage/payment dispute — the plan charged a higher copayment than it should have.
Reimbursement request — request reimbursement for a covered prescription drug you paid for out of pocket.

Documentation Required

inv-02: Submission and prescriber support requirements

If waiting 72 hours for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function, you may request an expedited (24-hour) decision. If the prescriber certifies the need, we will automatically decide within 24 hours. Expedited requests are not available for reimbursement requests for drugs already received.

Check the expedited review box if you believe a 24-hour decision is needed and attach a prescriber's supporting statement.
If you do not have a prescriber's statement, Priority Health will determine whether the case qualifies for expedited review.
You cannot request expedited review for reimbursement of a drug already dispensed.

Key Definitions

inv-05: Expedited decision

DefinitionExpedited decision: a request for a faster coverage determination when waiting the standard 72-hour timeframe could seriously harm the enrollee’s life, health, or ability to regain maximum function.

When prescriber supports urgencyIf the prescriber indicates that waiting 72 hours could seriously harm the enrollee, Priority Health will provide a decision within 24 hours.

Requester optionsRequester (enrollee, prescriber, or authorized representative) may check the request box for expedited review and must attach the prescriber’s supporting statement if available.

Plan determination without prescriber supportIf prescriber support is not provided, the plan will determine whether the case warrants expedited handling.

LimitationsAn expedited coverage determination cannot be requested for reimbursement-only requests for drugs already received (retroactive reimbursement).

inv-06: Formulary exception

DefinitionFormulary exception: a request when a needed drug is not on the plan’s formulary, has been removed from the formulary, is subject to tiering changes, or when a quantity limit/step therapy prevents access.

Prescriber requirementFormulary and tiering exception requests cannot be processed without a prescriber’s supporting statement; prescriber must provide clinical justification (use the attached supporting information form).

Types of formulary exceptionsIncludes requests for non-covered drugs, drugs removed from the formulary, tiering exceptions (lower copayment or prevent higher-tier move), and quantity limit exceptions.

Related requestsFormulary exception requests may overlap with prior authorization or other utilization management requirements and may require additional supporting information.