5 Steps To Complete Optum Rx Tier Exception Form

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When it comes to managing healthcare costs, pharmacy benefit management (PBM) companies like Optum Rx play a crucial role. One of the ways they help control costs is by using a tiered formulary system, where medications are categorized into different tiers based on their cost and therapeutic value. However, there may be situations where a medication is not available on the formulary or is not covered at the desired tier, requiring an exception. This is where the Optum Rx Tier Exception Form comes in.

Completing the Optum Rx Tier Exception Form can be a daunting task, especially for those who are not familiar with the process. In this article, we will guide you through the 5 steps to complete the form successfully.

Understanding the Optum Rx Tier Exception Form

Before we dive into the steps, it's essential to understand what the Optum Rx Tier Exception Form is and why it's necessary. The form is used to request an exception to the standard formulary coverage or tier placement for a specific medication. This can include requests for non-formulary medications, tier changes, or quantity limit exceptions.

Step 1: Gather Required Information

To complete the Optum Rx Tier Exception Form successfully, you will need to gather some required information. This includes:

• The patient's name and date of birth
• The medication name and dosage
• The patient's medical condition and diagnosis
• The prescribing physician's name and contact information
• The patient's medical history and relevant test results

Step 2: Determine the Type of Exception Request

The Optum Rx Tier Exception Form allows you to request different types of exceptions, including:

• Non-formulary exception: Requesting coverage for a medication that is not on the formulary
• Tier exception: Requesting a change in tier placement for a medication
• Quantity limit exception: Requesting an exception to the standard quantity limit for a medication

Choosing the Right Exception Type

It's essential to choose the right exception type to ensure that your request is processed correctly. If you're unsure, you can consult with the prescribing physician or contact Optum Rx customer support for guidance.

Step 3: Complete the Form

Once you have gathered the required information and determined the type of exception request, you can start completing the form. The form typically includes sections for:

• Patient information
• Medication information
• Prescribing physician information
• Medical condition and diagnosis
• Exception request type and justification

Tips for Completing the Form

• Make sure to fill out all required fields accurately and completely
• Use clear and concise language when describing the medical condition and justification for the exception request
• Attach any relevant medical documentation, such as test results or medical history

Step 4: Submit the Form

Once you have completed the form, you can submit it to Optum Rx for review. The form can be submitted via fax, email, or online portal, depending on the specific requirements of your plan.

Tracking the Status of Your Request

After submitting the form, you can track the status of your request by contacting Optum Rx customer support or checking the online portal. It's essential to follow up on the status of your request to ensure that it is processed in a timely manner.

Step 5: Follow Up and Appeal (If Necessary)

If your exception request is denied, you can appeal the decision by submitting additional information or clarification. It's essential to follow up on the appeal to ensure that it is processed correctly.

Tips for Appealing a Denied Request

• Review the denial letter carefully to understand the reason for the denial
• Gather additional information or clarification to support the appeal
• Submit the appeal in a timely manner to ensure that it is processed correctly

Conclusion

Completing the Optum Rx Tier Exception Form can be a complex process, but by following these 5 steps, you can ensure that your request is processed correctly. Remember to gather all required information, determine the correct exception type, complete the form accurately, submit the form in a timely manner, and follow up on the status of your request.