WebPrescription Drug Benefits. Maintenance Drug Refills. All maintenance medications must be filled in a 90-day supply at one of our Retail Maintenance Network pharmacies or through the Express Scripts mail service program. Visit express-scripts.com to search for a network pharmacy and view current medication costs. WebDec 1, 2024 · Exceptions. An exception request is a type of coverage determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception. A tiering exception should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier.
Tier Exception Form - FEP Blue
WebCompleted forms should be faxed to: 855-633-7673. It is not necessary to fax this cover page. Information about this Request for a Lower Copay (Tiering Exception) Use this form to request coverage of a brand or generic in a higher cost sharing tier at a lower cost sharing tier. Certain restrictions apply. WebMedical need for different dosage form and/or higher dosage . form(s) and/or dosage(s) tried and outcome of drug trial(s); (2) explain medical reason (3) include whyless frequent dosing with a higher strength is not an option – if a higher strength exists] ☐ Request for formulary tier exception . Specify below if not noted in the DRUG ... jimmy john\u0027s commercial
Prescription Drug Exceptions and Appeals - Humana
WebDec 13, 2024 · Enter your information. Attach supporting documentation for your appeal. If you need to fax supporting documentation, please fax the materials to 877-486-2621 (continental U.S.) or 800-595-0462 (Puerto Rico). Once Humana receives your request, we will provide written notice of our decision within 7 calendar days. WebSend completed form to: Service Benefit Plan Attn: Reconsideration P.O. Box 52080 Phoenix, AZ 85072-2080 FAX: 1-877-378-4727 CARDHOLDER OR PHYSICIAN … WebSend completed form to: Service Benefit Plan Attn: Reconsideration P.O. Box 52080 Phoenix, AZ 85072-2080 FAX: 1-877-378-4727 CARDHOLDER OR PHYSICIAN COMPLETES Tier Exception Member Request Form PHYSICIANONLYCOMPLETES R Cardholder Identification Number jimmy john\u0027s colorado springs briargate