Home
Forms Library
Tier Exception Form docx

Get the up-to-date Tier Exception Form docx 2025 now

Tier Exception Form docx Preview on Page 1

Show details

4.5 out of 5

39 votes

The document is a Tier Exception Member Request Form for requesting a copay exception for medications. It requires completion by both the cardholder or physician, detailing patient information, diagnosis, and medication history. The form must be sent to the Service Benefit Plan for reconsideration, and it includes instructions on how to submit multiple requests and notes on approval conditions.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

The best way to change Tier Exception Form docx online

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

With DocHub, making adjustments to your paperwork requires just a few simple clicks. Follow these quick steps to change the PDF Tier Exception Form docx online free of charge:

Register and log in to your account. Sign in to the editor using your credentials or click Create free account to examine the tool’s functionality.
Add the Tier Exception Form docx for redacting. Click on the New Document option above, then drag and drop the document to the upload area, import it from the cloud, or using a link.
Modify your document. Make any adjustments needed: add text and pictures to your Tier Exception Form docx, highlight details that matter, erase sections of content and replace them with new ones, and add symbols, checkmarks, and areas for filling out.
Finish redacting the form. Save the modified document on your device, export it to the cloud, print it right from the editor, or share it with all the parties involved.

Our editor is super easy to use and effective. Give it a try now!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to get tier exception approved?

Call your insurance company and ask them if they have a tier exception process? Ask them if they have a form your medical provider can complete and submit on your behalf.

How do I get a Tier Exception approved CVS?

Tier Exception There should be documentation to show that the lower-cost sharing alternative drug(s) were not effective. To request a tier exception: Fax a Tier Exception Form to CVS Caremark at 1-888-487-9257. Call CVS Caremark at 1-800-294-5979.

What is a tier exception form?

A tiering exception request letter can help make medication more affordable for patients covered through Medicaid or TRICARE who may not be eligible to participate in savings programs but need assistance covering costs.

How long does a tier exception take?

Once submitted, your doctor should hear back about your plans decision within a couple days after the request. If approved, your medication will be covered at cost-sharing that applies in the lower tier.

How to write a tier exception letter?

The reason I am requesting a tiering exception is because the cost associated with [product] assigned tier would present a financial burden to [patients name]. Furthermore, it prevents my patient from utilizing a medication that will help treat the [condition].

How to get a tier exception approved?

A tiering exception request is a way to request lower cost-sharing. 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.

Get the up-to-date Tier Exception Form docx 2025 now

Here's how it works