Tier Exception Letter Sample With Medicare
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How to fill out Sample Letter For Exception To Determination Of Civil Penalty?
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FAQ
It is usually helpful to include a letter of support from your prescribing physician. This letter should explain why similar drugs on the plan's formulary at lower tiers are ineffective or harmful for you. Your plan must give you a decision within 72 hours of receiving the request.
? Your doctor is your ally on this. Most plans require that your doctor submit a formulary exception on your behalf. The doctor will need to send paperwork to your health plan indicating the reason that you can't take the preferred medications and must have one that is not currently on the formulary.
TIER EXCEPTION CRITERIA FOR APPROVAL The member must have tried at least three alternative formulary medications that are on a lower tier and approved to treat the same condition as the requested medication AND the member either did not respond to or did not tolerate the formulary alternative medications.
A tiering exception is a drug plan's decision to charge a lower amount for a drug that's on its non-preferred drug tier. You or your prescriber must request an exception, and your doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.
A tiering exception is a type of exception request through the Part D appeal process. You can request lower cost-sharing for a prescription on a higher tier if you show that similar drugs on the formulary at lower tiers are ineffective or harmful for you.