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Tearing Exception Request Complete this form to request an exception for the patient to receive the formulary medication at the formulary brand copay. Patient Information Patient Name: Date of Birth: Plan

How to fill out tiering exception request patient

How to fill out a tiering exception request for a patient:

1. Begin by gathering all the necessary information and documents. This includes the patient's full name, date of birth, and insurance information. Also, make sure to have their prescription details, such as medication name, dosage, and duration of treatment.
2. Access the tiering exception request form. This can typically be obtained from the insurance company's website or by contacting their customer service. Follow any specific instructions mentioned on the form.
3. Start by filling in the patient's personal information accurately. Double-check the details to avoid any mistakes or discrepancies.
4. Provide the reason for the tiering exception request. This could be due to medical necessity, previous ineffective treatments, or allergies to other medication options. Clearly explain why the prescribed medication is required and necessary for the patient's well-being.
5. Attach any supporting documentation that strengthens the case for a tiering exception. This may include medical records, doctor's notes, test results, or any other relevant information. These documents will help demonstrate the medical necessity of the requested medication.
6. Review the form thoroughly before submitting it. Make sure all sections are filled out correctly, and all necessary documents are attached. Pay attention to any additional requirements or signatures needed.
7. Once the form is complete, submit it as per the instructions provided. This usually involves mailing, faxing, or uploading the form and supporting documentation online. Keep copies of all the submitted documents for your records.

Who needs a tiering exception request for a patient:

1. Patients who have been prescribed a medication that is not covered by their insurance plan's formulary.
2. Patients whose insurance plan requires additional steps before covering a specific medication, such as trying other alternatives first, even if they have already proven ineffective.
3. Patients whose health conditions warrant an exception from the usual coverage rules established by their insurance plan. This could include situations where the prescribed medication is critical for their well-being or where the alternatives are known to be less effective or cause adverse reactions.

Remember, it is crucial to consult the insurance plan's guidelines and policies to determine if a tiering exception request is necessary and to ensure accurate completion of the request form.

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