Updated: 01/01/2020.

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150 0 obj <>/Filter/FlateDecode/ID[<98C413DF7BF9424497E070B611CB3499><16CD287EA480DA428324A5E9912CEA96>]/Index[127 52]/Info 126 0 R/Length 104/Prev 53614/Root 128 0 R/Size 179/Type/XRef/W[1 2 1]>>stream %���� h�b``e``�� [/3�F fa�h@�b�P~�5 Retail Pharmacy Mail Service Pharmacy. 127 0 obj <> endobj <>>> EXCEPTION PROCESS New to Market FDA-Approved Medication Review Exception Process allows a member to apply for coverage of an excluded drug at a tier 3 cost share if a member has tried and failed the covered drug(s). To submit request electronically, please go to covermymeds.com using Plan/PBM Name “BCBS NC” Fax: 888-446-8535 . All fields below must be completed to begin processing the Formulary Tier Exception request. The Non-Formulary Exception (NFE) process allows FEP Blue Focus members to request coverage of a non-formulary drug if they …

Box 52080 Phoenix, AZ 85072-2080 FAX: 1-800-273-5357 If you are requesting a copay exception for more than one medication, please use a separate form for eachmedication. �����rV-y ��{t��[�-h����z�&C+H���{o^�畷QLZ����h�h�4˙� 178 0 obj <>stream ����&+R�C8��vv�g<4ix�L�iz�pxq�Rg���?fFfE�lT�U ɶc����SMmii�)|�4��� ���ƿ��b��QP�S��)�l��~tf����o�0�S����ʈs�d�ʋxF�)��d�A9�ܛ|H��_���hd�u���~� <> 4 0 obj

Services rendered outside of Massachusetts: Submit to your Local Plan Clinical Exception and Notification Form for the following IMRT medical policies must be filled out and submitted prior to any of the below IMRT treatments: IMRT of the Breast and Lung, #163 IMRT of … ®, SM Marks of the Blue Cross and Blue Shield Association. _��0�.x���\���G���e 9����^�:�8��ۑ������20�_�ed0 (=

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Formulary Tier Exception Member Request Form.

Ask your physician if there is a generic drug available to treat your condition. �MD� �� �.�` qy}A�@\�M M �������R��8����g @1| endstream endobj 128 0 obj <>/Metadata 3 0 R/PageLayout/OneColumn/Pages 125 0 R/StructTreeRoot 7 0 R/Type/Catalog>> endobj 129 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Type/Page>> endobj 130 0 obj <>stream For all formulary tier exceptions you will need to complete and file a request form. endobj Tier Exception Request Form An independent licensee of the Blue Cross and Blue Shield Association. Please note the following restrictions; a formulary exception request is for non-covered self-administered drugs only. Medicare Plus Blue PPO non-Michigan Skilled Nursing Facility, Acute Rehabilitation Facility Fax Assessment Form (PDF) Medicare Plus Blue PPO LTACH Fax Assessment Form (PDF) ���h�����>�S��D6[����W4���h5?0��l.�,�B%�]�����5V(�7��ٍ*�6�7�6�Qi�������K�c�45�,f��l~Pή+���ID�U��ݽ����?�I�����G��Z]ӿ?�C,�T�bD� �)����J�����S6�h�:F����Hb9Zj��s��R�-P]ڒ��brzzR��;�W ��|�I�~��8�L��|]'Ň�ꡚ�DŽ��?����.+�ǤY}���E���.����.����

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exception override will be applied either to the retail pharmacy OR the mail service pharmacy – please indicate where you would like to obtain your medication. Formulary Tier Exception Member Request Form Service Benefit Plan Attn: Reconsideration P.O. stream 'lB5��U*�[������L�VW�w-�kY���Υ{W�uY#]l@��b�������z=��z�½���Z�P}�Z7�J����3��Λ�3�b��7뚢��k�m:�ovX_���[ݎb&4���fr��C��21�

Tier exception requests may be approved if documentation is provided that medications used to treat the condition in the lower cost sharing tier(s) were ineffective or are contraindicated. �|c^̾�G�鲚��]���y>[���vu�Ի���Y�j�U��� �`2�@�%�s�i�~�[ &�Hԥb���)x$> �g41줈�K(��0҂)Uf����+4�#�(�S��aD��I���T�c�=_��nK�Hns˃ �mƂ� Review Form. %%EOF 3 0 obj Formulary Exception Request (Non-Medicare) You may request an exception to your prescription medication coverage for drugs that are not included on your prescription drug list. Exception Form .

Benefit Enhancement Assessment Form (PDF) LTACH and Skilled Nursing Facility Enhancement Assessment Form (PDF) Medicare Plus Blue PPO. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>

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FEP® Blue Focus Formulary (907) Effective July 7, 2020 The FEP formulary includes a preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs, preferred generic specialty drugs, and preferred brand-name specialty drugs.

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