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Tier Exception (cost-share reduction) Request form
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Form and instructions for prescribers to request a Tier Exception to reduce a patient's medication cost-share under Aetna; applies to prescribers and affected members and notes that PA/UM requirements must be satisfied first. Non-formulary and specialty drugs are not eligible.
No material clinical or coverage changes in this revision.
Tier Exception Coverage Criteria
Tier Exception Review Criteria
Tier exception will be considered when ALL of the following are provided
See attestation text and signature requirement.
If applicable, include supporting clinical information for PA/UM.
Include current/past medications, dates of treatment, and therapeutic outcomes.
Requests for ineligible drugs will not be reviewed.
Non-formulary and specialty drugs are not eligible for Tier Exceptions. Requests for drugs that are not on the plan formulary or that are designated as specialty products will not be reviewed under the Tier Exception process and should not be submitted as Tier Exception requests.
Required Provider Actions and Documentation
Prior Authorization / Utilization Management Must Be Satisfied First
If a drug has prior authorization (PA) or other Utilization Management (UM) requirements, those PA/UM requirements must be satisfied before a Tier Exception request can be reviewed. Provide all supporting clinical information for any PA/UM requirements along with the Tier Exception request.
- Ensure any required PA/UM is approved or documentation submitted prior to submitting a Tier Exception request.
Non‑Formulary and Specialty Drugs Ineligible
Requests for non-formulary drugs and specialty drugs are not eligible for Tier Exceptions and will be denied. Do not submit a Tier Exception request for a drug that is non-formulary or designated specialty.
- Non-formulary and specialty drugs: ineligible for Tier Exception — expect denial if submitted.
List Lower‑Tier Formulary Drugs Tried with Dates and Outcomes
The prescriber must list all lower-tier formulary drugs the patient has tried (include formulary generic equivalents when applicable) and provide dates of treatment and the therapeutic outcome or reason for discontinuation. Clinical information describing past effectiveness or adverse effects for each formulary alternative is required.
- For each lower-tier drug include: drug name (and generic equivalent if pertinent), dates of treatment, and therapeutic outcome or adverse effects.
- Document why lower‑tier alternatives would be less effective or likely to cause adverse effects for this enrollee.
Prescriber Supporting Statement and Required Attachments
A prescriber supporting statement is required for all Tier Exception requests. Attach all supporting clinical information, including verification that formulary alternatives were tried and any documentation submitted to meet PA/UM requirements. By signing, the prescriber attests to medical necessity and accuracy of the information provided.
- Attach prescriber statement and any clinical records that verify alternatives tried and outcomes.
- Include any PA/UM supporting documentation so the Tier Exception can be reviewed without delay.
Key Definitions
Background
A Tier Exception is an administrative request submitted by a prescriber to obtain a lower patient cost-share for a medication when a covered formulary alternative is unsuitable. The prescriber must provide a supporting statement and clinical documentation that verify why formulary alternatives would be less effective or would cause adverse effects, and must document prior treatment history. If the medication has any prior authorization (PA) or utilization management (UM) requirements, those requirements must be satisfied before the Tier Exception request can be reviewed.
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