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How to fill out the Tier Exception Request Form - Blue Cross and Blue Shield of North Carolina online
Filling out the Tier Exception Request Form is an essential process for securing necessary medications that may not be on the standard formulary. This guide will walk you through each section of the form, providing clear instructions to ensure your request is complete and accurately submitted online.
Follow the steps to fill out your Tier Exception Request Form effectively.
- Use the ‘Get Form’ button to access the Tier Exception Request Form and open it in your document editor.
- Begin by providing prescriber information: fill in the physician's name and their NPI number.
- Next, enter patient information: include the patient ID, name, sex, date of birth, address, and contact numbers.
- In the medication requested section, provide the name, strength, and dosage form required for the patient.
- Clearly state the diagnosis for which the requested medication is necessary.
- Indicate if this medication is a new prescription for the patient by checking either the ‘YES’ or ‘NO’ box.
- If applicable, list any lower-tier drugs the patient has tried, including details on their effectiveness or adverse effects.
- If you believe that lower-tier alternatives are not suitable, provide a detailed clinical rationale explaining the expected differences in efficacy or potential adverse effects.
- Complete the final section by signing and dating the form, confirming the accuracy of the information provided.
- Once filled out, you can save your changes, download the completed form, print it out, or share it as required.
Complete your Tier Exception Request Form online for a smoother process.
Benefit Exception Inquiry: a formal written request completed by the member's assigned Care Coordinator or Care Coordination entity to request a service or item outside of the standard benefit set covered by the product, or request to exceed Department of Human Services (DHS) case mix cap for MSHO/MSC+ Elderly Waiver ( ...
Fill Tier Exception Request Form - Blue Cross And Blue Shield Of North ...
Tier exception requests cannot be considered for medications that have been approved as a formulary exception. If a member chooses to change plans during the benefit year exception approvals may no longer be valid. Medicare Part D Prescription Coverage Request Form – TIER EXCEPTION. Each drug in the formulary is assigned a tier under your benefit plan. Each tier is associated with a copayment or coinsurance amount. Tier Exception Member Request Form. Certain restrictions apply. Type of Coverage Determination Request.
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