Tier Exception Form
Tier Exception Form - To submit request electronically, please go to covermymeds.com using plan/pbm name “bcbs nc”. Request for a medicare prescription drug coverage determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception.
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For consideration of the drug to be lowered to a different cost tier, 1) all the lower tier alternatives must have. For tiering exception requests, you or your doctor must show that drugs for treatment of your condition that are on lower tiers are ineffective or dangerous for you. To request a tiering exception, you or your doctor must show that the drugs for treatment of your.
All Fields Below Must Be Completed To Begin Processing The Formulary Tier Exception Request.
Tier Exceptions For Generic Medications Will Be Approved To The Lowest Tier Which Contains Generic Alternatives.
(1) formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; To submit a formulary or tiering exception, use the forms below: A prescriber supporting statement is required for tier exception.
An Enrollee, An Enrollee's Representative, Or An Enrollee's Prescriber May Use This Model.
Information About This Request For A Lower Copay (Tiering Exception) Use This Form To Request Coverage Of A Brand Or Generic In A Higher Cost Sharing Tier At A Lower Cost.
Use this form to request coverage of a brand or generic in a higher cost tier at a lower cost tier.
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