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Medicare Part D Coverage Determination Request Form Now Available

A standardized coverage determination request form for the Part D Medicare Prescription Drug benefit has been developed through a collaborated effort between an AMA Part D work group and the health insurance industry. ACP has been an active participant within this process. The Centers for Medicare and Medicaid Services (CMS) is requesting that all plans use this form as a “best practice” and representatives of the health insurance industry expect wide acceptance.

The development of this standardized form is in response to providers’ complaints regarding complications caused by each plan having a different exceptions/appeals form.

The form can be used to request approval for a drug not in a plan’s formulary, for an exception to a formulary tier, and for providing data to meet prior authorization requirements. The form can be used for all drugs except those specifically not covered under the Part D benefit (i.e. barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs or prescription vitamins other than prenatal vitamins and fluoride preparations) and biotech or high cost specialty drugs.

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