Mass Advantage Medicare Advantage

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

Attach Document/File

I need a drug that is not on the plan's list of covered drugs (coverage determination).*

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 (coverage determination).*

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.

Additional information we should consider (attach any supporting documents):

Attach Document/File

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 *

Use your mouse or finger to draw your signature above

Date *

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

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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

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)

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?

Any FDA NOTED CONTRAINDICATIONS to the requested drug?

Any concern for a DRUG INTERACTION with the addition of the requested drug to the enrollee's current drug regimen?

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

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?

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

Is the stated daily MED dose noted medically necessary?

Would a lower total daily MED dose be insufficient to control the enrollee's pain?

Required Explanation

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Type of Coverage Determination Request

Important Note: Expedited Decisions

Supporting Information for an Exception Request or Prior Authorization

DRUG HISTORY: (for treatment of the condition(s) requiring the requested drug)

Drug Safety

HIGH RISK MANAGEMENT OF DRUGS IN THE ELDERLY

OPIOIDS - (please complete the following questions if the requested drug is an opioid)

RATIONALE FOR REQUEST