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Express scripts tier exception 2026
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- Click ‘Get Form’ to open the express scripts tier exception in the editor.
- Begin by entering the Patient Information. Fill in the patient's first and last name, date of birth, ID number, and phone number.
- Next, provide Prescriber Information. Include the prescriber's name, DEA/NPI number, phone number, fax number, and address.
- Indicate the Primary Diagnosis and corresponding ICD Code. This is crucial for processing the request accurately.
- Select the requested drug and strength from the provided options. Ensure you check all that apply.
- Fill in Directions for use clearly to avoid any confusion regarding dosage.
- Complete the clinical assessment questions by selecting Yes, No, or N/A as appropriate for each question.
- Add any additional comments or important information in the designated section to assist with review.
- Finally, ensure that both Prescriber Signature and Date are filled out before submitting your form.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2013 | 4.8 Satisfied (101 Votes) |
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express scripts formulary exception form
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You can also apply for a non-formulary exception. You can contact them at 1-844-345-4577, press option #2.**Please
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