Express scripts tier exception 2026

1. Click ‘Get Form’ to open the express scripts tier exception in the editor.
2. Begin by entering the Patient Information. Fill in the patient's first and last name, date of birth, ID number, and phone number.
3. Next, provide Prescriber Information. Include the prescriber's name, DEA/NPI number, phone number, fax number, and address.
4. Indicate the Primary Diagnosis and corresponding ICD Code. This is crucial for processing the request accurately.
5. Select the requested drug and strength from the provided options. Ensure you check all that apply.
6. Fill in Directions for use clearly to avoid any confusion regarding dosage.
7. Complete the clinical assessment questions by selecting Yes, No, or N/A as appropriate for each question.
8. Add any additional comments or important information in the designated section to assist with review.
9. Finally, ensure that both Prescriber Signature and Date are filled out before submitting your form.

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