2012 Tier Exception Request Form - SCAN Health Plan-2026

1. Click ‘Get Form’ to open the 2012 Tier Exception Request Form in our platform.
2. Begin by entering the member's last name, first name, SCAN ID number, and date of birth in the designated fields.
3. Fill in the prescriber’s name, contact person, office phone, and office fax to ensure proper communication.
4. Specify the requested Tier 4 medication and provide a brief diagnosis related to the request.
5. Answer the questions regarding drug interactions, adverse effects, contraindications, and effectiveness of Tier 3 alternatives. Provide detailed responses for each question.
6. Include any additional comments or relevant information that may assist in the review process.
7. Review all entered information for accuracy before submitting the form through our editor.

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