Medicare Part D enrollees, their representatives and prescribers use this CMS model form to ask a drug plan to cover a drug: prior authorization, a formulary or utilization-management exception, a tiering exception, or reimbursement. Prescribers meet it most often as the supporting statement for an exception. The plan must decide within 72 hours for a standard request or 24 hours for an expedited one.
The enrollee, a representative or the prescriber completes pages 1 and 2: enrollee details, the drug, the type of request and whether an expedited decision is needed. The prescriber completes pages 3 and 4, Supporting Information for an Exception Request or Prior Authorization, and a representative other than the prescriber attaches a CMS-1696 or equivalent.
Enter the enrollee's name, date of birth, address, phone and member ID number. If the person making the request is neither the enrollee nor the prescriber, add the requestor's name, relationship to the enrollee, address and phone, and attach documentation of authority to represent the enrollee: a completed CMS-1696 or an equivalent. A prescriber filing the request does not need this appointment.
Name the drug, with dosage and quantity if available, then check the request type. The first group covers a higher copayment than expected, reimbursement for a covered drug paid out of pocket and prior authorization. The second group requires a prescriber statement: a drug not on the formulary, a drug being removed during the plan year, step therapy, quantity limit or prior authorization exceptions, and tiering exceptions for a lower copayment.
Check YES for a decision within 24 hours if waiting 72 hours could seriously harm the enrollee's life, health or ability to regain maximum function, and attach the prescriber's supporting statement if there is one. With the prescriber's support, the plan grants the faster timeline automatically; without it, the plan decides whether the case qualifies. Reimbursement requests cannot be expedited. The requester signs and dates, then mails or faxes the form to the plan.
Page 3 is completed by the prescriber. To ask for expedited review, check the box and sign, certifying that the 72-hour standard timeframe may seriously jeopardize the enrollee's life, health or ability to regain maximum function. Then enter the prescriber's name, street address, office phone and fax, and sign and date the prescriber information block.
Give the medication, strength and route, frequency, date started or new start, expected length of therapy, quantity per 30 days, height and weight and drug allergies. List every diagnosis treated with the drug with ICD-10 codes; when the condition is a symptom such as weight loss or chest pain, give the underlying diagnosis if known. Add other relevant diagnoses and the drug history: drugs tried, trial dates and results, labeled as failure or intolerance, with unit and daily doses when a quantity limit is the issue.
State the enrollee's current regimen for the condition. Answer whether there are FDA-noted contraindications or drug interaction concerns; if yes, explain the issue, the benefits against the risks and the monitoring plan. For enrollees over 65, say whether the benefits outweigh the risks. For opioids, give the daily cumulative morphine equivalent dose, whether other opioid prescribers are known, and whether that dose is medically necessary and a lower dose would be insufficient.
Check each reason that applies and explain it: alternate drugs tried with an adverse outcome or therapeutic failure (with maximum dose and length of therapy), alternatives contraindicated or likely less effective, adverse effects if the prior authorization requirement had to be met, stability on the current drug with high risk from a change, a need for a different dosage form or higher dose, a formulary tier exception, or other. Most boxes require a specific explanation of the expected adverse clinical outcome.
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Request for Medicare Drug Coverage Determination
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The enrollee, the enrollee's prescriber or an authorized representative. A prescriber can file for the enrollee without being appointed as a representative; anyone else filing on the enrollee's behalf attaches a completed Appointment of Representative form CMS-1696 or an equivalent document. The prescriber also signs the supporting information on page 3.
72 hours for a standard request and 24 hours for an expedited one. For exceptions, the clock starts when the plan receives the prescriber's supporting statement. If the prescriber indicates that waiting 72 hours could seriously harm the enrollee's health, the plan automatically decides within 24 hours. Requests for reimbursement are decided within 14 calendar days.
A tiering exception asks for a non-preferred drug at the lower cost sharing of a preferred tier. A formulary exception asks for a drug that is not on the plan's formulary, or waives a utilization management rule such as step therapy, prior authorization or a quantity limit for a covered drug. Both need a prescriber supporting statement.
No. CMS allows the request on its model form, a plan-developed form or any other written document. Many plans post a branded copy with their own address and fax filled in, which saves looking them up, since the CMS model leaves those blanks for each plan to insert. Benefit requests can also be made verbally.