SCAN Health Plan Tier Exception Form 2011-2025 free printable template

Express Scripts Phone (800) 417-8164 Fax 877-837-5922 Tier Exception Form (Applicable to the Part D formulary tier 4 drugs of a 5-tier formulary) Member s Last Name: Member s First Name: SCAN ID number:

How to fill out SCAN Health Plan Tier Exception Form

How to fill out SCAN Health Plan Tier Exception Form

1. Obtain the SCAN Health Plan Tier Exception Form from the SCAN website or your health care provider.
2. Fill out the patient information section, including name, date of birth, and policy number.
3. Indicate the specific medication for which the tier exception is being requested.
4. Provide the reason for the exception request clearly and concisely.
5. Attach any supporting medical documentation, such as a prescription or a letter from the prescribing doctor.
6. Review the form for accuracy and completeness.
7. Submit the form to the appropriate address provided on the form, either by mail or electronically.

Who needs SCAN Health Plan Tier Exception Form?

1. Individuals enrolled in the SCAN Health Plan who require a tier exception for their medication.

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What is SCAN Health Plan Tier Exception Form?

The SCAN Health Plan Tier Exception Form is a document used by members to request an exception to the standard tiered formulary, allowing them access to medications that may not be covered or are placed on a higher tier.

Who is required to file SCAN Health Plan Tier Exception Form?

Members who want to request an exception to their medication coverage under the SCAN Health Plan must file the Tier Exception Form.

How to fill out SCAN Health Plan Tier Exception Form?

To fill out the SCAN Health Plan Tier Exception Form, members should provide personal information, specify the medication for which the exception is requested, explain the medical necessity for the request, and submit any supporting documentation.

What is the purpose of SCAN Health Plan Tier Exception Form?

The purpose of the SCAN Health Plan Tier Exception Form is to enable members to request coverage for medications that are not typically covered under their plan's formulary, facilitating access to necessary treatments.

What information must be reported on SCAN Health Plan Tier Exception Form?

The SCAN Health Plan Tier Exception Form must report the member's personal information, the specific medication in question, the tier level of the medication, the reason for the exception request, and any relevant medical information or supporting documents.