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Get Cigna Tier Exception Form

Et and your request is approved, the copayment will be lowered one tier until the end of the calendar year. Medicare Part D guidance does NOT allow tier exceptions for medications that are not on our formulary. 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 u.

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