Get Cigna Tier Exception Form

Filling out the Cigna Tier Exception Form online is essential for prescribers seeking a copay reduction on medications for Cigna Medicare Services plan members. This guide offers a clear, step-by-step approach to ensure that the form is completed accurately and efficiently.

Follow the steps to successfully complete the Cigna Tier Exception Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing the required provider information. Fill in the provider's name, specialty, DEA or TIN, office contact person, and office phone. Complete the office street address and city.
3. Next, enter the patient's information. Include the patient's name, ID number, date of birth, and contact details. Also, indicate the patient's street address, city, state, and zip code.
4. Specify the medication requested. Include the name of the drug, strength, monthly quantity prescribed, dosage, and expected duration of therapy.
5. Provide clinical data. Insert the diagnosis related to the medication use and include the ICD-9 code if available. Check all relevant reasons for the copay reduction/tier exception request, such as therapy failures or contraindications.
6. For each reason checked, provide supporting details and any alternative medications that were tried. If applicable, specify any contraindications and include original therapy start dates along with positive response details.
7. If the situation requires urgent processing, check the expedited/urgent box and sign the form to certify the necessity of prompt review.
8. Once all required sections are filled out accurately, you may save changes, download, print, or share the form as needed.

Complete your documentation online and streamline the process by following these instructions.