CMS-10191 CDAG Supplemental Questions

CDAG_SupplementalQuestions

Question #

Question

1

Identify the entity that processes coverage determinations for your organization (i.e.,
processed in house, by a PBM, by another entity).

2

Identify the entity that processes redeterminations for your organization (i.e., processed in
house, by a PBM, by another entity). If different than coverage determinations, explain
how information is shared between all entities that are involved in the decision making
process.

3

Is there a policy which indicates how many formulary drugs must be tried and failed before
a non-formulary drug is approved? Y/N

4

If response to #3 is yes, please attach the portion of your policy that specifically addresses
this question.

5

Please explain your mailroom policies and/or procedures as related to beneficiary
notification.

6

When effectuating approved cases, what level GPI or GCN is used? If effectuating using
another method please explain.

7

Define the look-back criteria utilized by your organization for step therapy. If smart- logic
is utilized for automatic look backs please describe this process.

8

Identify the entity that processes grievances for your organization (i.e., handled in house,
by a PBM, or by another entity).

9

Identify the entity responsible for incoming CDAG calls on evenings, weekends, and
holidays?

10

Are all Medicare related inquiries handled at the same call center or is there a distinct line
for Part D inquiries and requests?

Response