Coverage Determination

COVERAGE DETERMINATION FORM

Enrollee's Info

Requestor's Info

Drug Info

Questions

Sub Section

Attachments

Enrollee's Information

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.

Click here to download a manual form.

Enrollee's Name

Date of Birth

Enrollee's Address Required

City Required

State Required

Zip Code Required

Phone Required

Enrollee's Member ID #

Requestor's Information

Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Requestor's Name

Requestor's Relationship to Enrollee

Address

City

State

Zip Code

Phone

Representation documentation for requests made by someone other than enrollee or the enrollee's prescriber

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-MEDICARE.

Name of prescription drug you are requesting Required

Type of Coverage Determination Request

I need a drug that is not on the plan’s list of covered drugs (formulary exception).*

I have been using a drug that was previously included on the plan’s list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception).*

I request prior authorization for the drug my prescriber has prescribed.*

I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception).*

I request an exception to the plan’s limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my prescriber prescribed (formulary exception).*

My drug plan charges a higher copayment for the drug my prescriber prescribed than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception).*

I have been using a drug that was previously included on a lower copayment tier, but is being moved to or was moved to a higher copayment tier (tiering exception).*

My drug plan charged me a higher copayment for a drug than it should have.

I want to be reimbursed for a covered prescription drug that I paid for out of pocket.

*NOTE: If you are asking for a formulary or tiering exception, your prescriber MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may use the attached "Supporting Information for an Exception Request or Prior Authorization" to support your request.

Additional information we should consider

(attach any supporting documents)

Important Note: Expedited Decisions

If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 24 HOURS (if you have a supporting statement from your prescriber, attach it to this request).

Signature Required

Date Required

Supporting Information for an Exception Request or Prior Authorization

FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber’s supporting statement. PRIOR AUTHORIZATION requests may require supporting information.

REQUEST FOR EXPEDITED REVIEW: By checking this box and signing below, I certify that applying the 72 hour standard review timeframe may seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function.

Prescriber's Information

Name Required

Address

City Required

State Required

Zip Code

Office Phone

Fax

Diagnosis and Medical Information

Medication Required

Strength and Route of Administration Required

Frequency Required

Date Started

NEW START

Expected Length of Therapy Required

Quantity per 30 days Required

Height/Weight Required

Drug Allergies Required

DIAGNOSIS - Please list all diagnoses being treated with the requested drug and corresponding ICD-10 codes.
(If the condition being treated with the requested drug is a symptom e.g.anorexia, weight loss, shortness of breath, chest pain, nausea, etc., provide the diagnosis causing the symptom(s) if known)

ICD-10 Code(s)

Other RELEVANT DIAGNOSES

ICD-10 Code(s)

DRUG HISTORY: (for treatment of the condition(s) requiring the requested drug)

DRUGS TRIED (if quantity limit is an issue, list unit dose/total daily dose tried)

DATES of Drug Trials

RESULTS of previous drug trials FAILURE vs INTOLERANCE (explain)

1) DRUGS TRIED (if quantity limit is an issue, list unit dose/total daily dose tried) Required

DATES of Drug Trials Required

RESULTS of previous drug trials FAILURE vs INTOLERANCE (explain) Required

2) DRUGS TRIED (if quantity limit is an issue, list unit dose/total daily dose tried)

DATES of Drug Trials

RESULTS of previous drug trials FAILURE vs INTOLERANCE (explain)

3) DRUGS TRIED (if quantity limit is an issue, list unit dose/total daily dose tried)

DATES of Drug Trials

RESULTS of previous drug trials FAILURE vs INTOLERANCE (explain)

4) DRUGS TRIED (if quantity limit is an issue, list unit dose/total daily dose tried)

DATES of Drug Trials

RESULTS of previous drug trials FAILURE vs INTOLERANCE (explain)

What is the enrollee's current drug regimen for the condition(s) requiring the requested drug? Required

DRUG SAFETY

Any FDA NOTED CONTRAINDICATIONS to the requested drug?

Yes

Any concern for a DRUG INTERACTION with the addition of the requested drug to the enrollee’s current drug regimen?

Yes

If the answer to either of the questions noted above is yes, please 1) explain issue, 2) discuss the benefits vs. potential risks despite the noted concern, and 3) monitoring plan to ensure safety

HIGH RISK MANAGEMENT OF DRUGS IN THE ELDERLY

If the enrollee is over the age of 65, do you feel that the benefits of treatment with the requested drug outweigh the potential risks in this elderly patient?

Yes

OPIOIDS - (please complete the following questions if the requested drug is an opioid)

What is the daily cumulative Morphine Equivalent Dose (MED)?

mg/day

Are you aware of other opioid prescribers for this enrollee?

Yes

If so, please explain.

Is the stated daily MED dose noted medically necessary?

Yes

Would a lower total daily MED dose be insufficient to control the enrollee’s pain?

Yes

RATIONALE FOR REQUEST

Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g.toxicity, allergy, or therapeutic failure Specify below if not already noted in the DRUG HISTORYsection earlier on the form: (1) Drug(s) tried and results of drug trial(s), (2) if adverse outcome, list drug(s) and adverse outcome for each, (3) if therapeutic failure, list maximum dose and length of therapy for drug(s) trialed, (4) if contraindication(s), please list specific reason why preferred drug(s)/other formulary drug(s) are contraindicated.

Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change A specific explanation of any anticipated significant adverse clinical outcome and why a significant adverse outcome would be expected is required – e.g. the condition has been difficult to control (many drugs tried, multiple drugs required to control condition), the patient had a significant adverse outcome when the condition was not controlled previously (e.g. hospitalization or frequent acute medical visits, heart attack, stroke, falls, significant limitation of functional status, undue pain and suffering),etc.

Medical need for different dosage form and/or higher dosage Specify below: (1) Dosage form(s) and/or dosage(s) tried and outcome of drug trial(s), (2) explain medical reason, (3) include why less frequent dosing with a higher strength is not an option – if a higher strength exists.

Request for formulary tier exception Specify below if not noted in the DRUG HISTORY section earlier on the form: (1) formulary or preferred drug(s) tried and results of drug trial(s), (2) if adverse outcome,list drug(s) and adverse outcome for each, (3) if therapeutic failure/not as effective as requested drug, list maximum dose and length of therapy for drug(s) trialed, (4) if contraindication(s), please list specific reason why preferred drug(s)/other formulary drug(s) are contraindicated.

Other (explain below)

Required Explanation

Attach any additional information pages or supporting documents in PDF.