A Tiering Exception is a process in healthcare where patients can request coverage for a medication listed in a higher tier of their insurance plan’s formulary at a lower cost. Typically, insurance plans categorize medications into tiers based on cost and may require higher copayments or coinsurance for drugs in higher tiers. However, if a patient’s healthcare provider determines that a specific medication is medically necessary and more affordable options have been ineffective or inappropriate, they can submit a request for a Tiering Exception. This process involves providing clinical justification and evidence to the insurance provider to demonstrate the medical necessity of the medication. If approved, the patient may obtain the prescribed medication at a lower cost, helping to ensure access to necessary treatments while managing healthcare expenses.
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