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Brand penalty exception form 2025

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The document is a Brand Penalty Exception Request form that allows prescribers to request approval for a patient to receive a brand-name drug instead of a generic alternative, ensuring the patient pays only the brand copayment. It requires detailed patient and prescriber information, along with specific clinical justifications for the request, such as inadequate response to the generic or allergies. The form must be completed accurately to avoid processing delays.

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Click ‘Get Form’ to open the brand penalty exception request in the editor.
Begin by filling out the Patient Information section. Enter the patient's name, date of birth, and Plan Member ID Number.
Next, complete the Prescriber Information section. Input the prescriber's name, phone number, and fax number.
In the Brand Drug Name field, specify the requested brand-name drug along with its strength and dosage form.
Provide a diagnosis for the patient that justifies this request.
Answer each of the three questions regarding treatment response and appropriateness of generic alternatives. Be sure to document any specific clinical concerns as needed.
Finally, ensure that the prescriber signs and dates the form before submitting it. Fax it to the Exceptions Department at 1-888-487-9257.

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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.

What is pharmacy exception processing?

A formulary exclusion exception (exception) process is available to support Plan members who, per their provider, have a medical necessity to remain on an excluded drug.

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.

How hard is it to get a formulary exception?

you have pretty good odds of getting the formulary exception approved when it is a continuation of therapy (in your case) vs a new therapy. they will just have to document what youve tried and failed, and how what youre on now is working well for you and usually it is approved when you are already on the medication.

What is a prescription tier exception?

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 to request a tiering exception?

It is usually helpful to include a letter of support from your prescribing physician. This letter should explain why similar drugs on the plans formulary at lower tiers are ineffective or harmful for you. Your plan must give you a decision within 72 hours of receiving the request.

exception form

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What is a coverage exception form?

A coverage determination (exception) is a decision about whether a drug prescribed for you will be covered by us and the amount youll need to pay, if any.

What is a brand penalty exception?

Brand Penalty Exception Request Complete this form to request an exception for a patient to receive a brand-name drug instead of a generic alternative and pay only the appropriate brand copayment.

Brand penalty exception form 2025

Here's how it works

How to use or fill out brand penalty exception form with our platform

Complete this form in 5 minutes or less

Got questions?

What is pharmacy exception processing?

How do I get a Tier Exception approved CVS?

How hard is it to get a formulary exception?

What is a prescription tier exception?

How to request a tiering exception?

Complete this form in 5 minutes or less

People also ask

What is a coverage exception form?

What is a brand penalty exception?

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