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D for prescriber use to request a Formulary Exception, Prior Authorization or Step Therapy Exception for CIGNA Medicare Services plan members. Failure to complete this form in its entirety may result in an adverse determination for insufficient information. PROVIDER INFORMATION PATIENT INFORMATION * Provider Name: Specialty: **Due to privacy regulations we will not be able to respond via fax with the outcome of our review unless all asterisked (*) items on this form are completed** * DEA o.

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Tier 3—Non-preferred, brand-name prescription drugs. Higher copayment. Specialty tier—Very high cost prescription drugs. Highest copayment or coinsurance.

A formulary is a list of generic and brand name prescription drugs covered by your health plan. Non-formulary drugs typically only include brand-name medications and come with high out-of-pocket expenses. Your health plan may only help you pay for the drugs listed on its formulary.

A tiered formulary divides drugs into groups based mostly on cost....What is a tiered formulary? Drug tierType of drugs includedYour costTier 1Most generic drugsLowest copayTier 2Most common brand name drugs Preferred brand name drugs Some high-cost generic drugsMedium copayTier 3Non-preferred brand name drugsHighest copay1 more row

If a medication is “non-formulary,” it means it is not included on the insurance company's “formulary” or list of covered medications. A medication may not be on the formulary because an alternative is proven to be just as effective and safe but less costly.

Level or Tier 1: Low-cost generic and brand-name drugs. Level or Tier 2: Higher-cost generic and brand-name drugs. Level or Tier 3: High-cost, mostly brand-name drugs that may have generic or brand-name alternatives in Levels 1 or 2. Level or Tier 4: Highest-cost, mostly brand-name drugs.

Tier 3 - Nonpreferred Brand: Tier 3 is made up of nonpreferred, brand-name drugs that do have a generic option. Since there are more cost-effective alternatives available for these drugs, you'll have the highest copayment or these drugs may not be covered.

The most commonly prescribed classes of non-formulary drugs were immunobiologicals (vaccines), antiemetics, vitamins, psychotropic drugs, beta blockers, and systemic antimycotics and antibacterials.

If a medication is “non-formulary,” it means it is not included on the insurance company's “formulary” or list of covered medications. A medication may not be on the formulary because an alternative is proven to be just as effective and safe but less costly.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232