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This article provides information to ensure better drug coverage
determination outcomes for you and your Medicare Advantage HMO and PPO patients
who are covered under the Medicare Part D program through Independence. Please
note that for these members, prior authorization is required for coverage of
certain drugs approved by the U.S. Food and Drug Administration for specific
medical conditions.
Prior authorizations and overrides
To eliminate the need for additional outreach when processing coverage
determination requests, follow the tips below:
- Prior to submitting a request, review the Centers for Medicare &
Medicaid Services (CMS)
approved prior
authorization criteria to ensure you understand what information needs to
be provided.
- Always attach supporting documentation when it's available. Examples of
supporting documentation include chart notes and laboratory results.
Please note that if the request is for a high-risk medication (as defined on
the
Beers Criteria list), a statement must be
included in the request demonstrating that the provider is both:
- Aware of the risk of use of that drug in the elderly
- Still opting to prescribe that drug
Prior
authorization forms
Independence, in conjunction with FutureScripts® Secure, an
independent company, provides drug-specific forms for drugs that require prior
authorization. Completing the necessary prior authorization forms will reduce
the need for outreach to the physician's office and could avoid denials being
issued due to lack of information. A link to FutureScripts
Secure's prior authorization forms can be found on their website and on
Independence NaviNet® Plan Central in the Administrative Tools
and Resources section.
If a drug-specific form is not available for the drug requested, please use
the General Pharmacy (Quantity Edit/Prior Authorization) form.
Request
time frames
Time frame requirements must be considered when submitting a request. Per CMS
guidelines, Medicare Part D plans
are required to adhere to the following time frames for reviewing requests:
- Standard: 72 hours to process.
- Urgent (life-threatening to the member): 24 hours to process.
Requests submitted on Fridays, especially urgent requests, often require
additional information to complete the review. Please ensure that you or
someone in the office is available to provide additional information, if
needed, during non-business hours and weekends. Also note that the call may
come from a FutureScripts Secure representative.
Drug formularies
The formulary-based prescription drug benefits program includes all generic
drugs and a defined list of brand drugs that have been chosen for formulary
coverage based on their reported medical effectiveness, positive results, and
value. There are two types of drug formularies:
- Open formulary. All Medicare Part D drugs are considered "formulary"
and are available for coverage. Some drugs on an open formulary may require
prior authorization.
- Closed formulary. Only the drugs listed on the formulary are
covered. Drugs not listed on the formulary are considered non-formulary and
therefore not covered. In order to obtain a non-formulary drug, the physician
must request consideration for a formulary exception.
Formulary
exceptions
When submitting a Non-Formulary Exception request, keep in mind the following:
- All formulary exception requests must include a supporting clinical
statement.
- The member must try and fail at least three formulary alternatives when
available or have a documented reason why he or she cannot try and fail the
formulary alternatives.
Please note that when a formulary exception is approved, the drug will default
to the "non-preferred brand" tier, and the member will be charged the
cost-sharing associated with that tier (unless the member is in the coverage
gap, catastrophic, or deductible phase of their benefit). Also, approvals for
formulary exceptions will remain in effect until the end of the coverage
year.
The FutureScripts Non-Formulary Exception Request Form can be found
on the Provider
Forms page on our website.
Tier
exceptions
Once a drug is approved through the formulary exception process, the plan is
prohibited from also approving a tier exception for that drug.
- Similar to formulary exceptions, a supporting clinical statement is
required to demonstrate that the member has tried at least three lower-tiered
formulary alternatives when available or documentation to support intolerance
or contraindication to the formulary alternatives.
- Tier exceptions can only be approved for a non-preferred brand drug,
allowing the member to pay the preferred brand cost-sharing. Tier exceptions
cannot be approved to lower the cost of non-preferred generic drugs, to charge
generic cost-sharing for any brand drug, or to lower the cost-sharing for any
drug on the specialty tier.
Please note that the member's Medicare Part D benefit still applies. All
applicable deductible and/or coverage gap cost-sharing applies, and members
will be required to pay the applicable cost-sharing in that phase of their
benefit.
To submit a tier exception, use the FutureScripts Non-Formulary Exception
Request Form.
Ramifications and more information
Lack of adherence to the above process can lead to a delay in members
receiving coverage for their medication and/or increased outreach attempts by
Independence or FutureScripts to your office. In cases where information in a
request is incomplete and outreach attempts are unsuccessful, requests for
coverage may be denied and are subject to the appeals process.
If you have any questions regarding this process, please contact Customer
Service at 1-800-ASK-BLUE.
FutureScripts and FutureScripts Secure are independent
companies that provide pharmacy benefits management services.
NaviNet
is a registered trademark of NaviNet, Inc., an independent company.
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