Tier Exception Form docx 2026

1. Click ‘Get Form’ to open the Tier Exception Form in the editor.
2. Begin by entering the date at the top of the form. This is essential for tracking your request.
3. Fill in the patient’s name, including first, middle initial, and last name. Ensure accuracy for proper identification.
4. Provide the patient’s address, including street, city, state, and zip code. This information is crucial for correspondence.
5. Enter the patient’s date of birth and select their sex by marking 'M' or 'F'.
6. For physician completion, detail the patient's diagnosis and specify the brand drug name for which you are requesting a copay exception.
7. Indicate dosing directions clearly to avoid any confusion during processing.
8. Select whether there have been therapeutic failures or adverse events with previous medications and provide detailed descriptions as required.
9. Finally, ensure that all physician fields are completed accurately before signing and dating the form.

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