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, the copayment will be lowered to the preferred brand copayment on the plan until the end of the calendar year. Medicare Part D guidance does NOT allow tier exceptions for brand-name medications for generic copayments. 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.

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