Blue exception tier form 2025

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A tiering exception is a type of coverage determination used when a medication is on a plans formulary but is placed in a nonpreferred tier that has a higher co-pay or co-insurance. Plans may make a tier exception when the drug is demonstrated to be medically necessary.
Tier 3: Preferred brand drugs These are brand-name drugs that dont have a generic equivalent. Theyre the lowest-cost brand-name drugs on the drug list.
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.
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.
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].
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