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2016 Tier exception (cost share reduction) request Page 1 of 2 (You must complete both pages.) Please Note: This form is intended for prescriber used to request a Tier Exception to reduce the cost

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How to fill out b2016b tier exception cost-share

How to fill out b2016b tier exception cost-share:

01

Start by gathering all the necessary information and documentation required to fill out the form. This may include your personal details, medical history, and any supporting documents from your healthcare provider.

02

Begin filling out the form by providing your personal information such as your name, address, contact number, and insurance details. Make sure all the information is accurate and up to date.

03

Next, move on to the section where you need to provide details about the specific medication or treatment for which you are requesting a tier exception cost-share. Include the name, dosage, frequency, and any additional relevant information.

04

In the form, there should be a section where you can explain why you believe a tier exception cost-share should be applied. This is where you can provide a detailed explanation of your medical condition, previous treatments, and why the requested medication or treatment is necessary for your well-being.

05

If there are any supporting documents from your healthcare provider that can strengthen your case, make sure to attach them to the form. These may include medical records, test results, or a doctor's prescription.

06

Review the completed form to ensure all the information is accurate and legible. Double-check if any sections have been missed or if any corrections need to be made.

Who needs b2016b tier exception cost-share:

01

Individuals who have been prescribed a medication or treatment that falls under a higher tier in their insurance plan's formulary may need b2016b tier exception cost-share.

02

Those who cannot afford the high out-of-pocket costs associated with medications or treatments in a higher tier might be eligible for b2016b tier exception cost-share.

03

People with specific medical conditions that require a medication or treatment not available in lower tiers may also require b2016b tier exception cost-share.

Remember, the exact eligibility criteria for b2016b tier exception cost-share may vary depending on your insurance plan. It's always best to consult with your insurance provider or refer to the plan's guidelines to determine if you meet their requirements.

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