Fillable REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION (John Hopkins Medicine Medicare Plan)

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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION (John Hopkins Medicine Medicare Plan)

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Y0124_DeterminationFormPPO0920_C
REQUEST FOR MEDICARE PRESCRIPTION DRUG
COVERAGE DETERMINATION
This form may be sent to us by mail or fax:
Address:
Johns Hopkins Advantage MD
c/o CVS Caremark Part D Services
Coverage Determination and Appeals Department
P.O. Box 52000 MC109
Phoenix, AZ 85072-2000
Fax Number:
1-855-633-7673
You may also ask us for a coverage determination by phone at 1-877-293-5325 (option 2), TTY:
711, October 1 through March 31 – Monday through Sunday, 8 a.m. to 8 p.m. and April 1 through
September 30 – Monday through Friday, 8 a.m. to 8 p.m. or through our website at
www.hopkinsmedicare.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
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
City State Zip Code
Phone
Y0124_DeterminationFormPPO0920_C
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, TTY: 1-
877-486-2048, 24 hours per day, 7 days a week.
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):
Y0124_DeterminationFormPPO0920_C
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: 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
Address
City
State Zip Code
Office Phone
Fax
Prescriber’s Signature
Date
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:
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Y0124_DeterminationFormPPO0920_C
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 RELAVENT 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)
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? ☐ YES ☐ NO
Any concern for a DRUG INTERACTION with the addition of the requested drug to the enrollee’s current
drug regimen? ☐ YES ☐ NO
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 ☐ NO
Y0124_DeterminationFormPPO0920_C
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?
If so, please explain.
☐ YES ☐ NO
Is the stated daily MED dose noted medically necessary? ☐ YES ☐ NO
Would a lower total daily MED dose be insufficient to control the enrollee’s pain? ☐ YES ☐ NO
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 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
_____________________________________________________________________________
_____________________________________________________________________________
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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION (John Hopkins Medicine Medicare Plan)

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Completed 25 May 2021

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