REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

This form may be sent to use by mail or fax.
Address:
First Choice VIP Care Plus
200 Stevens Drive
Philadelphia PA , 19113
Attn: Pharmacy Prior Authorization/Member Prescription Coverage Determination
Fax Number:
Standard: (855)825-2711
Urgent: (855)825-2712
• You may also ask us for a coverage determination by phone at (888)978-0862 or through our website at www.firstchoicevipcareplus.com .


• 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.
• Enrollee's Information

  Enrollee's Name		Date of Birth
  Enrollee's Address
  Enrollee's Address 2
  City	State	Zip Code
  Phone	Enrollee's Member ID #

  
  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		Address 2
  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). This documentation should be attached under the Attachments section of this request form below. For more information on appointing a representative, contact your plan or 1-800-Medicare.
• • Name of prescription drug you are requesting (if known, include strength and quantity requested per month);
    

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 DECISION WITHIN 24 HOURS (if you have a supporting statement from your prescriber, attach it to this request).

• Signature:

  Date:

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	Practice Name
  NPI	Specialty -- Select -- Adolescent Medicine Alcohol & Substance Abuse Allergy Allergy & Immunology Ancillary Pre-Natal Care Anesthesiology Audiology Blood Products Supplier Cardiology Cardiothoracic Surgery Cardiovascular Case Management Cert Reg Nurse Anes CRNA Cert Reg Nurse Pract OBGY Cert Reg Nurse Practitioner Chiropractor Chiropractor Clinical Pharmacology Critical Care Dermatology Dermopathology Developmental Rehab Diabetes Educator Diabetology Dialysis Center Ears/Nose/Throat Emergency Room Physician Endocrinology Endodontists EPSDT MH Wraparound Family Practice FP, Maternal & Child Health Gastroenterology General Dentistry General Practice General Surgery Genetics Genetics and Infertility Geriatrics Gynecologic Oncology Gynecology Hematology Hematology & Oncology Hematology/Oncology HIV/AIDS Case Mgt Svcs Home Infusion Hospital Pathology Host HMO Immunology Infectious Disease Internal Medicine IV Therapy-Infusion Therapy Lithotripsy/Kidney Maternal Fetal Medicine Med Resonance Imaging Center Mental Retardation Metabolism Midwife Multiple Specialty Group Neonatology Nephrology Neuro-Ophthalmology Neurological Surgery Neurology Neuropathology Neurophysiology No Specific Medical Specialty Nuclear Medicine Nurse Practitioner Nutritionist OB/Gynecology Obstetrics Obstetrics Occularist Occulo Plast Reconst Surg Occupational Medicine Occupational Therapist Oncology Ophthalmic Pathology Ophthalmology Ophthalmology - Cornea Ophthalmology - Glaucoma Ophthalmology - Retina Ophthalomology-Plastic Recon Optical Supply Optician Optometry Oral and Maxillofacial Surgeon Oral Pathology Oral Surgery Orthodontics Orthodontists Orthopaedics Orthotics & Prosthetics Osteopathy Otorhinolaryngology Pain Management Pathology Pathology, Clinical Pediatric Anesthesiology Pediatric Critical Care Pediatric Dentistry Pediatric Genetics Pediatric Surgery Pediatrics Pediatrics Otorhinolaryngology Pediatrics, Allergy Pediatrics, Cardiology Pediatrics, Dermatology Pediatrics, Developmental Pediatrics, Emergency Medicine Pediatrics, Endocrinology Pediatrics, Gastroenterology Pediatrics, Hem/Onc Pediatrics, Hematology Pediatrics, Immunology Pediatrics, Infectious Disease Pediatrics, Internal Medicine Pediatrics, Metabolism Pediatrics, Nephrology Pediatrics, Neurology Pediatrics, Neurosurgery Pediatrics, Nurse Practitioner Pediatrics, Oncology Pediatrics, Ophthalmology Pediatrics, Orthopedic Surgery Pediatrics, Pathology Pediatrics, Pulmonology Pediatrics, Radiology Pediatrics, Rheumatology Pediatrics, Urology Pedodontics Periodontics Personal Care Pharmacist Physical Medicine & Rehab Physical Therapy Physician Assistant Plastic Surgery Podiatry Preventative Medicine Preventative Medicine Primary Care Vision Private Duty Nursing Private Mental Health Prosthetics & Orthotics Prosthodontics Psych Rehab-Subst Abuse Psychiatry Psychiatry, Child Psychiatry, Neurology Psychologist Pulmonary Disease Radiation Oncology Radiology Radiology, Diagnostic Radiology, Interventional Neur Radiology, Neuro Radiology, Therapeutic Reproductive Endocrinology Reproductive Genetics Rheumatology SED Children Sleep Disorders Social Worker Speech Pathology Speech Therapy Surgery, Cardiovascular Surgery, Colon and Rectal Surgery, Hand Surgery, Oncology Surgery, Orthopedic Surgery, Pathology Surgery, Pediatric Surgery, Plast. Maxillofacial Surgery, Plastic, Facial Surgery, Thoracic Surgery, Transplant Surgery, Urological Therapist-Multi Spec Group Urgent Care Urogynecology Urology Vascular Medicine Vascular Surgery Vitreoretinal Surg Xray
  Address
  Address 2
  City	State	Zip Code
  Office Phone	Fax	Contact Person
  Prescriber's Signature:	Date:

• Attachments:
• • Attachments are optional. If needed you can upload and attach files to this request.
    The following file extensions are allowed: ".pdf, .doc, .docx, .xls, .xlsx, .ppt, .txt"
    Files must be 3 MB (3,000,000 bytes) or less.

  • ---

  • Attachment Type:
    Authorization of Representation Form (CMS-1696) Formulary Exception Documentation Tiering Exception Documentation Exception request Supporting Information Prior Authorization Supporting Information Expedited Request Supporting Information Chart Notes Lab Results Sample Logs Other
  • Select a file to upload:
     

Diagnosis and Medical Information

• Medication:	Strength and Route of Administration:	Frequency:
  Date Started: New Start	Expected Length of Therapy:	Quantity per 30 days:
  Height/Weight:	Drug Allergies:
  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 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 DIAGNOSIS:		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)	Date 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?

DRUG SAFETY

Any FDA NOTED CONTRAINDICATIONS to the requested drug? NO YES

Any concern for a DRUG INTERACTION with the addition of the requested drug to the enrollee's current drug regimen? NO YES

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 the elderly patient? NO 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? NO YES

Is the stated daily MED dose noted medically necessary? NO YES Would a lower total daily MED dose be insufficient to control the enrollee's pain? NO 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 HISTORY section 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 contraindiction(s), please list specific reason why preferred drug(s)/other formaulary 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 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 HISTROY 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

First Choice VIP Care Plus is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits for both programs to enrollees.
H8213_001_FRM_709581_Accepted_10312019