CurrentUCarePolicy N/A

Request for Medicare Drug Coverage Determination (Prior Authorization / Formulary Exception)

This document is the UCare form and instructions for requesting a Medicare drug coverage determination (prior authorization, formulary exception, reimbursement, or tiering/quantity exceptions) used by enrollees, prescribers, or authorized representatives.

Policy Summary

PayerUCare

PolicyRequest for Medicare Drug Coverage Determination (Prior Authorization / Formulary Exception)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must submit prescriber-completed supporting documentation including diagnosis (ICD-10), complete drug history, medication details, and prescriber signature when requesting prior authorization or formulary exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1primary form for Medicare drug coverage determination

24+distinct form sections or checklist items (estimate)

24/7phone and web submission options referenced

24hexpedited decision turnaround when prescriber certifies harm

Coverage Determination Criteria

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Initial coverage determination criteria

Covered when ALL of the following are provided and documented:

Essential documentation: Prescriber information (name, address, phone, signature), medication details (name, strength, route, frequency, quantity, date started or NEW START indicator), expected length of therapy, height/weight, and drug allergies.

Supports clinical review

Prior drug history: Complete drug history including drugs tried, dates of drug trials, results (therapeutic failure vs intolerance vs adverse outcome), and whether failure or intolerance; current regimen must be stated.

Required for formulary exceptions and quantity limits

Rationale categories: One or more of: alternate drug(s) previously tried with adverse outcome or therapeutic failure; alternative drug(s) contraindicated or would not be as effective; patient would suffer adverse effects if required to satisfy prior authorization; patient stable on current drug(s) with high risk from medication change; medical need for different dosage form and/or higher dosage.

Check applicable rationale boxes and provide detailed explanation as requested on the form

Safety information: FDA contraindications and specific reasons must be reported; include potential drug interactions, monitoring plan, and for patients >65 an assessment that benefits outweigh risks.

Safety queries must be answered to support review

This form does not list additional explicit coverage exclusions on its face; it provides checkboxes for multiple request types (prior authorization, formulary exception, tiering or quantity exceptions, reimbursement) and asks for supporting documentation when required. Use the form fields and prescriber-completed 'Supporting Information for an Exception Request or Prior Authorization' pages to document the clinical details needed for review.

Requests that do not include the required prescriber statement or supporting documentation may be denied. The form instructs that prescribers must complete the supporting information pages when requesting prior authorization or formulary exceptions and requests specific rationale for exceptions (e.g., prior drug trials, contraindications, failure or intolerance); failure to document these items can result in denial of the request.

Diagnosis and Coding

Diagnosis codes requestedICD-10

ICD-10

Space provided to list ICD-10 diagnosis codes for conditions treated with requested drug

Expedited decision timeframe

Expedited decision timeframeDecision within 24 hours when prescriber certifies that waiting 72 hours could seriously harm the enrollee; standard review timeframe is 72 hours.

Prescriber supportIf prescriber indicates waiting 72 hours could seriously harm the enrollee, attach supporting statement to request to trigger 24-hour decision.

No expedited for reimbursement requestsExpedited decision cannot be requested when asking for reimbursement for a drug already received.

Provider Responsibilities and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required: Prescribers must complete and submit the prescriber-completed supporting information form when requesting prior authorization. The form must include prescriber information, signature, medication name (with strength, route, frequency), dates (e.g., date started), expected length of therapy, quantity per 30 days, and diagnosis with corresponding ICD-10 code(s). Expedited review may be requested when applying the standard timeframe would seriously jeopardize the enrollee's life or health.

Prescriber name, office address, phone, fax, signature and date are required.
Medication details: name, strength, route, frequency, date started, new start vs continuation, expected length of therapy, and quantity per 30 days.
Diagnosis: list all diagnoses treated with the requested drug and corresponding ICD-10 code(s).

Prior Authorization

Formulary Exception Documentation Required

Formulary exception requests require a prescriber statement and documentation of trials or a specific medical justification to waive step-therapy or other requirements. Document prior trials of required alternative drugs (drug name, dates of trial, dose and duration, and outcome) or provide a clear rationale (contraindication, intolerance, therapeutic failure, or clinical reason why alternatives are not appropriate). For tiering exceptions, document trials of formulary/preferred drugs and the outcomes.

If a brand is requested when a generic/biosimilar is available, prescriber must justify why the generic/biosimilar is not appropriate.
For quantity-limit exceptions, list unit dose/total daily dose tried and dates, and explain why the requested quantity is medically necessary.

Documentation Required

Documentation to Submit with Request

Provider must submit supporting documentation with the request. Include the DRUG HISTORY section completed by the prescriber: drugs tried, dates of drug trials, results (failure vs intolerance), current drug regimen, and any relevant clinical notes or test results. If relying on adverse outcomes or contraindications, specify the drug(s) and the nature of the adverse outcome or the clinical reason for contraindication. Attach any additional medical records that substantiate the request.

Complete Drug History: drug names, dates, results, maximum dose and length of therapy when claiming therapeutic failure.
Rationale: explain anticipated significant adverse clinical outcomes if alternatives are used, stability on current therapy, or medical need for different/higher dosage form.

Denial Risk

Incomplete Requests May Be Denied

Denial risk: Requests lacking a prescriber statement or adequate supporting documentation (diagnosis with ICD-10, prescriber signature, drug history with dates and outcomes, or specific rationale for exceptions) may be denied. Failure to document required trials, contraindications, intolerance, or provide necessary clinical detail for quantity/tiering/prior authorization exceptions increases the likelihood of denial.

Incomplete forms (missing prescriber signature, missing ICD-10 codes, or absent drug trial dates/results) may not be processed and are at high risk for denial.
Be specific: vague statements without dates, doses, or clinical notes are insufficient.

Policy Background

The purpose of this form is to collect the clinical and safety information necessary to evaluate Medicare drug coverage determination requests — including prior authorizations, formulary exceptions, tiering or quantity-limit exceptions, and reimbursement requests. It gathers patient and prescriber identification, the type of request, medication details, and directs the prescriber to provide supporting clinical information on the 'Supporting Information for an Exception Request or Prior Authorization' pages so that the plan can assess medical necessity and appropriate coverage.

Key Definitions

Expedited review definition

DefinitionA faster decision timeline: we will automatically give a decision within 24 hours when the prescriber certifies that waiting the standard 72 hours could seriously harm the enrollee's life, health, or ability to regain maximum function.

Prescriber certification requiredPrescriber must indicate that waiting 72 hours could seriously harm the enrollee; attach supporting statement to the request.

Adjudication without prescriber supportIf prescriber support is not provided, the plan will decide whether the case requires an expedited (fast) decision.

Initial Therapy Requirements

Initial therapy requirements

Information required to evaluate initiation of a requested drug:

Initial therapy documentation: Medication name, strength, route, frequency, date started (or indicate NEW START), expected length of therapy, quantity per 30 days, and drug allergies.

Required to assess appropriateness for initiation

Drug history when applicable: List prior drugs tried for the condition, dates of trials, results of previous drug trials including failure vs intolerance, and unit dose/total daily dose if quantity limit is an issue.

Needed to evaluate step therapy and quantity-limit exceptions

Diagnosis coding: Provide all diagnoses being treated and corresponding ICD-10 code(s).

Needed for clinical indication verification

Continuation / Maintenance Therapy

Continuation/maintenance therapy

When requesting continuation of therapy or to avoid switching after removal from formulary:

Continuation rationale: Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change; or prior adverse events when drug changed. Provide specific explanation of clinical risk or previous adverse events.

Used to support formulary exception for continuity of care

Step Therapy Exception Requirements

Requirement	What prescriber must provide
Documentation that alternative drug(s) were previously tried but resulted in adverse outcome or therapeutic failure
List drugs tried, dates, results of trials; if adverse outcome, specify the adverse event for each; if therapeutic failure, list maximum dose and duration used
Statement that alternative drug(s) are contraindicated or likely to be less effective
Specific explanation why preferred/alternative drug(s) are contraindicated or why they would not be as effective; describe anticipated significant adverse clinical outcome and rationale
Explanation if patient would suffer adverse effects from meeting the prior authorization/step requirement
Specific explanation of anticipated significant adverse clinical outcome and why it would be expected if the patient were required to satisfy the step therapy requirement
Reason to continue current therapy to avoid switching (continuation rationale)
Description of stability on current drug(s) and specific explanation of high risk for significant adverse clinical outcome with medication change (e.g., prior hospitalization, serious events, difficult-to-control condition)
Request for different dosage form or higher dosage
Specify dosage form(s)/dosage(s) tried and outcomes; explain medical reason for requested form/dose and why alternatives (e.g., higher strength less frequent dosing) are not suitable

Quantity Limit Exceptions

Any requested drug — quantity limit and drug history

Documentation requirementFor any requested drug, requester must document medical need for an exception to a quantity limit and list unit dose and total daily dose tried.

Drug history detailsProvide DRUGS TRIED, DATES of drug trials, and RESULTS (including failure vs intolerance) in the DRUG HISTORY section.

If quantity-limit issueIf quantity limit is an issue, specifically list unit dose/total daily dose tried and include outcomes of those trials.

Rationale cross-referenceInclude relevant rationale boxes (e.g., adverse outcome, therapeutic failure, contraindication) in RATIONALE FOR REQUEST to support quantity exceptions.