Optumrx Tier Exception Form. Forms are updated frequently and may be barcoded. Please fill out all applicable sections on both pages completely and legibly.
Cvs Caremark Tier Exception Form
Who may make a request: Web optumrx tier exception form is a request form that allows a patient to request a medication that is a higher tier on their insurance formulary. Web this form may be sent to us by mail or fax: Web prescription drug prior authorization or step therapy exception request form patient name: Start completing the fillable fields and carefully type in required information. You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). Web partial copay waiver (pcw) exception prior authorization request form. Optumrx is not authorized to review requests for medications supplied by the physician’s office. Use the cross or check marks in the top toolbar to select your answers in the list boxes. Your plan may have multiple or no tiers.
You may also ask us for a coverage determination by calling the member services number on the back of your id card. Do not copy for future use. Use the cross or check marks in the top toolbar to select your answers in the list boxes. Forms are updated frequently and may be barcoded. Web this form may be sent to us by mail or fax: Web partial copay waiver (pcw) exception prior authorization request form. Start completing the fillable fields and carefully type in required information. Web to submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., hcr), please contact the optumrx® pa department through telephone or fax. Web optumrx tier exception form is a request form that allows a patient to request a medication that is a higher tier on their insurance formulary. Web prescription drug prior authorization or step therapy exception request form patient name: Your plan may have multiple or no tiers.
