Get the free Specialty Formulary Tier Exception Member Request Form

Send completed form to: Service Benefit Plan Attn: Reconsideration P.O. Box 52080 Phoenix, AZ 850722080 FAX: 18773784727Specialty Formulary Tier Exception Member Request Form CARDHOLDER OR PHYSICIAN

How to fill out specialty formulary tier exception

How to fill out specialty formulary tier exception

1. To fill out a specialty formulary tier exception, follow these steps:
2. Obtain the specialty formulary tier exception form from your healthcare provider or insurance company.
3. Review the eligibility criteria for the exception to ensure you qualify for it.
4. Complete the patient information section on the form, providing necessary personal details.
5. Get a written statement or prescription from your healthcare provider explaining the medical necessity for the requested medication.
6. Attach any supporting documentation, such as medical records or test results, that validate the need for the exception.
7. Sign and date the form, and ensure all required fields are filled out.
8. Submit the completed form along with the supporting documents to your insurance company via mail, fax, or online portal.
9. Keep a copy of the form for your records.
10. Wait for a response from your insurance company regarding the approval or denial of the exception request.

Who needs specialty formulary tier exception?

1. Specialty formulary tier exception is needed by individuals who require medications that fall under a higher tier on their insurance company's formulary.
2. These medications are typically more expensive and may require prior approval or meet certain criteria before being covered by insurance.
3. Patients who have tried and failed lower-tiered medications, or for whom alternative treatments are not effective, may be eligible for a specialty formulary tier exception.
4. It is recommended to consult with your healthcare provider and insurance company to determine if you qualify for this exception.

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What is specialty formulary tier exception?

A specialty formulary tier exception is a request made by a patient or healthcare provider to obtain coverage for a specialty medication that is not listed in the preferred formulary tier, allowing the patient to access necessary medications at potentially reduced costs.

Who is required to file specialty formulary tier exception?

Typically, the healthcare provider or the patient can initiate the filing of a specialty formulary tier exception depending on the insurance company's policies.

How to fill out specialty formulary tier exception?

To fill out a specialty formulary tier exception, one must complete the designated form provided by the insurance provider, including patient information, medication details, justifications for the exception, and supporting medical documentation.

What is the purpose of specialty formulary tier exception?

The purpose of the specialty formulary tier exception is to allow patients who require specialty medications that are not on the standard formulary to access those medications, often due to medical necessity.

What information must be reported on specialty formulary tier exception?

Information that must be reported includes patient demographics, medication name and dosage, the reason for the exception request, and relevant clinical information or documentation supporting the medical need.