Part D Coverage Determination Form
User Manual: Part-D-Coverage-Determination-Form
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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: GuildNet Pharmacy Services 441 9th Avenue New York, NY 10001-1681 Fax Number: 1-877-300-9695 You may also ask us for a coverage determination by phone at 1-855-283-2148 or through our website at www.guildnetny.org. 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. Participant’s Information Participant’s Name _____________________________________ Date of Birth _______________ Participant’s Address _______________________________________________________________ City ___________________________ State______________ Zip Code _______________ Phone ___________________________ Participant ID # __________________________ Complete the following section ONLY if the person making this request is not the participant or prescriber: Requestor’s Name ____________________________________________________________ Requestor’s Relationship to Participant _____________________________________________ Address ____________________________________________________________________ City __________________________________ State ________ Zip Code ______________ Phone _____________________________ Representation documentation for requests made by someone other than participant or the participant’s prescriber: Attach documentation showing the authority to represent the participant (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. 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 A DECISION WITHIN 24 HOURS (if you have a supporting statement from your prescriber, attach it to this request). Signature of person requesting the coverage determination (the participant, or the participant’s prescriber or representative): Date: Supporting Information for an Exception Request or Prior Authorization H0811 CDAG Form_GN Approved 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 participant or the participant’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: New Prescription OR Date Therapy Initiated: Height/Weight: Expected Length of Therapy: Drug Allergies: Frequency: Quantity: Diagnosis: Rationale for Request Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure [Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s)] Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change [Specify below: Anticipated significant adverse clinical outcome] Medical need for different dosage form and/or higher dosage [Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason] Request for formulary tier exception [Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome] Other (explain below) Required Explanation:___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ GuildNet Gold Plus FIDA Plan is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Program. Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. You can get this information for free in other languages. Call 1-800-815-0000 (TTY 1-800-662-1220), Monday through Sunday 8am to 8pm. The call is free. Usted puede obtener esta información en otros idiomas gratis. Llame al 1-800-815-0000 o TTY/TDD al 1-800662-1220, de lunes a domingo de 8am a 8pm. La llamada es gratis. Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde 1-800-815-0000 o 1-800-662-1220 mediante un telefono testuale per non udenti (TTY/TDD), da lunedì a domenica, dalle 8 alle 20. La chiamata è gratuita. 您可以免費獲得本信息的其他語言版本。 請撥打1-800-815-0000 或聽障／語障人士專線(TTY/TDD) 1-800-6621220， 星期一至星期日上午8 時至晚上 8 時。 撥打該電話免費。 Вы можете бесплатно получить эту информацию на других языках. Позвоните по телефону 1-800-8150000 и TTY/TDD 1-800-662-1220. Служба работает с понедельника по воскресенье с 08:00 до 20:00 ч. Звонок бесплатный. Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo 1-800-815-0000 oswa TTY/TDD 1-800662-1220, lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis. 다른 언어로 작성된 이 정보를 무료로 얻으실 수 있습니다. 월요일 - 일요일 오전 8시부터 오후 8시 사이에 1-800-815-0000번이나 TTY/TDD 1-800-662-1220번으로 전화주세요. 통화는 무료입니다. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by GuildNet Gold Plus FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org.
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