Blue exception tier form 2026

1. Click ‘Get Form’ to open the blue exception tier form in the editor.
2. Begin by entering the 'Today’s Date' at the top of the form. This is essential for tracking your request.
3. Fill in the 'Patient, Insurance and Physician/Clinic Information' section. Include details such as Patient Name, Insurance ID Number, and Prescribing Physician’s Name.
4. Indicate if the patient is a long-term care facility resident by selecting 'Yes' or 'No'. If 'Yes', provide additional contact information for the LTC facility.
5. In the 'Diagnosis' field, enter the ICD-9 code along with a brief description. This helps clarify the medical necessity of your request.
6. Specify the 'Medication Requested', including its strength and dosing schedule. Ensure accuracy to avoid delays.
7. Answer questions regarding current treatment status and previous medications tried. This information is crucial for justifying your request.
8. Once completed, review all entries for accuracy before submitting via fax or mail as indicated at the bottom of the form.

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