Currentpriority healthPolicy N/A

Request for Medicare Part D coverage determination

A form and instructions used by enrollees, prescribers, or authorized representatives to request a Medicare Part D coverage determination, including formulary exceptions, prior authorization, quantity-limit exceptions, tiering exceptions, expedited review requests, and associated supporting clinical/documentation fields. Provides submission methods and prescriber supporting information.

Policy Summary

Payerpriority health

PolicyRequest for Medicare Part D coverage determination

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionFor formulary exception or prior authorization requests the prescriber must complete the supporting information section including diagnosis with ICD-10 codes, drug history with dates and outcomes, current regimen, safety concerns, and rationale for the request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

10Request types listed

24Expedited decision (hours)

72Standard decision (hours)

Policy overview

This is the standard Medicare Part D coverage determination request form used by Priority Health Medicare plan enrollees, their prescribers, or authorized representatives to request coverage decisions, including prior authorizations, formulary exceptions, quantity- or tiering exceptions, reimbursement for certain charges, and expedited reviews. It requires the necessary clinical/supporting information from prescribers and provides submission instructions and contact options (phone, website, mail, fax).

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Types of requests covered by this form

Types of Requests

Select the applicable request type; some request types require prescriber supporting information.

Plan copayment error: Plan charged a higher copayment for a drug than it should have
Reimbursement for covered drug paid out-of-pocket: Reimbursement requested for a covered drug already paid for out-of-pocket
Prior authorization request for a prescribed drug (may require supporting information)
Formulary exception - non-formulary drug: Formulary exception: need a drug that's not on the plan's list of covered drugs
Formulary exception - drug removed during plan year: Formulary exception: drug previously covered but removed during plan year
Formulary exception - step therapy: Formulary exception: exception to step therapy (requirement to try another drug first)
Formulary exception - quantity limit: Formulary exception: exception to quantity limit
Formulary exception - prior authorization rules: Formulary exception: exception to prior authorization rules
Tiering exception - higher copayment versus alternative: Tiering exception: plan charges a higher copayment vs another drug treating same condition
Tiering exception - moved to higher tier: Tiering exception: drug moved to higher copayment tier

Expedited decision eligibility and limits

Expedited Decision Eligibility

Conditions for expedited (24-hour) decision:

Prescriber harm certification: Prescriber indicates that waiting 72 hours could seriously harm life, health, or ability to regain maximum function
Automatic 24-hour if prescriber supports: If prescriber supports, plan will automatically render decision within 24 hours24 hours
Plan may decide without prescriber support: If no prescriber support, plan will independently decide if expedited review is warranted

Denial Risk

Expedited request limitations

Expedited decisions are not available for requests to be reimbursed for a drug already received. A prescriber's certification/support is required to guarantee a 24-hour expedited decision when waiting 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function. If prescriber support is not provided, the plan will independently decide whether an expedited review is warranted.

Expedited decision hours if supported24

Standard decision timeframe (hours)72

Supporting information required from prescriber

Supporting Information Required from Prescriber

Prescriber must complete supporting information for exception or prior authorization requests. Include ALL applicable items:

Prescriber information: name, address, office phone, fax, signature, date
Medication details: name, strength, route, frequency, date started, NEW START indicator, expected length of therapy, quantity per 30 days, height/weight, drug allergies
Diagnosis and ICD-10 codes for condition(s) treated and relevant additional diagnoses
Drug history: drugs tried, dates of trials, results (failure vs intolerance), unit dose/total daily dose if quantity-limit related
Current drug regimen for the condition(s)
Drug safety: any FDA-noted contraindications (Yes/No) and any drug interaction concerns (Yes/No) with explanation and monitoring plan if yes
High-risk management (>65): High-risk management for patients >65: prescriber assessment that benefits outweigh risks (Yes/No)
Opioid-specific questions if requested drug is an opioid: daily MED (mg/day), other opioid prescribers (Yes/No), medical necessity of MED dose (Yes/No), whether lower MED would be insufficient (Yes/No)
Rationale for request: select(s) describing alternate drugs tried, contraindications, risk of adverse outcomes if PA enforced, stability on current drug, medical need for different dosage form/higher dosage, or formulary tier exception; provide supporting details

Documentation Required

Prescriber must provide supporting clinical information

For formulary exception or prior authorization requests the prescriber must provide supporting clinical information. Include diagnosis with corresponding ICD-10 codes, the enrollee's drug history with dates and outcomes (failure vs intolerance), the current drug regimen for the condition(s), any drug safety concerns (FDA-noted contraindications or potential drug interactions with explanation and monitoring plan), and the clinical rationale for the request.

Prior Authorization

Prior authorization/formulary exception submission requirement

Use this form (or phone/website) to request prior authorization or formulary exceptions. For expedited review, the prescriber must sign the form certifying that applying the 72-hour standard review timeframe may seriously jeopardize the enrollee's life, health, or ability to regain maximum function; prescriber signature is required for expedited review certification.

Submission channels, contact information, and representative documentation

Billing Rule

Submission channels and contact info

Submit the form and any supporting information by mail, fax, phone, or via the website. Mailing address: Priority Health Medicare MS 1260, 1231 East Beltline Ave NE, Grand Rapids, MI 49525. Fax: (877) 974-4411. Phone: (888) 389-6648. Website: prioritymedicare.com.

Documentation Required

Representative authorization documentation

If the requester is not the enrollee or the prescriber, submit documentation of authority to represent the enrollee (Authorization of Representation Form CMS-1696 or equivalent).

Action checklist for providers

Providers should: select the applicable request type on the form (e.g., prior authorization, formulary or tiering exception, quantity limit, reimbursement claim), complete the required prescriber supporting information (diagnosis with ICD-10 codes, drug history with dates and outcomes, current regimen, safety questions, rationale and other clinical details), include the prescriber signature/certification when requesting an expedited (24-hour) decision, attach documentation of representative authorization if acting for the enrollee, and submit the completed form and supporting documents via the listed channels (mail or fax) or use the phone/website options.