Prescribing Physician Request For Medicare Part D Prescription Drug Coverage Determination Form Page 2
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1
2Type of Coverage Determination Request
The member needs a drug that is not on the plan’s list of covered drugs (formulary exception). *
The member has 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). *
The member requests an exception to the requirement that he/she try another drug before getting the
drug prescribed (formulary exception). *
The member requests an exception to the plan’s limit on the number of pills (quantity limit) he/she can
receive so he/she can get the number of pills prescribed (formulary exception). *
The member’s drug plan charges a higher copayment for the drug prescribed than it charges for
another drug that treats his/her condition, and the member wants to pay the lower copayment (tiering
exception). *
The member has 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). *
The prescribed Part D drug requires prior authorization before being dispensed.
*Note: If you are asking for a formulary, tiering or quantity limitation exception, on behalf of the member,
you must provide a statement to support the request to BCBSF/Health Options. BCBSF/Health Options
will need the following information:
Tiering Exception – please indicate why:
•
The preferred drug would not be as effective for the member as the requested drug; and
•
The preferred drug would have adverse effects for the member.
Formulary or Quantity Limitation Exception – please indicate why the non-formulary drug or the
available quantity or dosing limitation would:
•
Be ineffective in the treatment of the member’s disease or medical condition;
•
Adversely affect the drug’s effectiveness or patient compliance; and
•
Have adverse effects for the member.
The member cannot ask for a tiering exception for a drug in the plan’s Specialty Tier. In addition, the
member cannot obtain a brand name drug at the copayment that applies to generic drugs.
Additional information we should consider (attach any supporting documents):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
If you, the prescribing physician, believes that waiting for a standard decision (which will be provided
within 72 hours) could seriously harm the member’s life or health or ability to regain maximum function,
you can ask for an expedited (fast) decision on behalf of the member. If you ask for an expedited decision
BCBSF/Health Options will give you a decision within 24 hours. If a member asks for a fast (expedited)
decision, they must obtain your support for why an expedited decision should be made. You may provide
this support in writing or by telephone to BCBSF/Health Options, that you believe waiting 72 hours could
seriously harm the member’s life or health or ability to regain maximum function, we will give a decision
within 24 hours.
900- 450-0107
January 2007
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