[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-162565-105":53,"doc-detail-162565-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","tiering-exception-letter-sample-template","Tiering Exception Letter Sample Template","","Tiering exception letter template for requesting access to a medication from a health plan when the drug is not available at the patient’s preferred formulary tier. The template guides clinicians to identify the patient, plan membership, diagnosis and ICD codes, prescribe product details, summarize prior treatment failures, and document unresolved symptoms. It also instructs on attaching medical records and a letter of medical necessity, explaining why lower-tier formulary drugs are not as effective and how higher-tier costs create financial hardship. Includes physician contact and enclosure list.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/tiering-exception-letter-sample-template/162565/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/tiering-exception-letter-sample-template/162565.png","ImageObject",442,249,{"name":88,"@type":89},"Ethan Miller","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-09-19","2026-08-30",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to identify the patient and prescription for a tiering exception request?","Question",{"text":108,"@type":109},"The letter template requests the patient’s name and health plan membership, plus the product name, dosage, and frequency. It also includes the diagnosis and ICD code(s).","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How should the clinician explain why the requested product is medically necessary?",{"text":113,"@type":109},"The letter asks the clinician to state that the product is medically appropriate and necessary and to request preferred access. It also provides space to explain why lower-tier formulary drugs would not be as effective and how the requested medication helps treat the condition.",{"name":115,"@type":106,"acceptedAnswer":116},"What supporting documents should be enclosed with the tiering exception letter?",{"text":117,"@type":109},"The template specifies enclosing copies of medical records and a Letter of Medical Necessity, along with items listed under enclosures such as financial hardship statements, case number, and any written response to denial. It also notes including clinical evaluation and supporting forms or photos when applicable.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},162565,1788126712,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},687207017582,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","To whom it may concern:\nMy name is [HCP’s name], and I am a [board-certified medical specialty] [NPI]. I am writing to request a tiering exception for my patient, [patient’s name], who is currently a member of [name of health plan].*\nThe prescription is for [product, dosage and frequency], which is medically appropriate and necessary for this patient who has been diagnosed with [condition], [ICD code(s)].\nI am requesting that [product] be made available to my patient as a preferred medication.\nIn the past, [patient’s name] has attempted other treatments for [condition], but those trials have failed due to either inadequate efficacy or lack of tolerability.\nThe patient’s present treatment(s) are as follows:\nCurrently, [patient’s name] has the following unresolved symptoms:\nAlong with this letter, I have enclosed a copy of my patient’s medical records and a Letter of Medical Necessity. \u000bThe letter describes why [product] is medically necessary for my patient’s care over the preferred drugs listed in \u000bthe plan’s formulary.\n[Explain why lower-tiered formulary drugs would not be as effective as product].\nThe reason I am requesting a tiering exception is because the cost associated with [product] assigned tier would present a financial burden to [patient’s name]. Furthermore, it prevents my patient from utilizing a medication that will help treat the [condition].\nTo summarize, I consider [product] to be the best option in successfully treating my patient’s [condition]. \u000bPlease contact me, [name], at [telephone number] to answer any pending questions.\nSincerely,\n[Physician’s name and signature]\n[Physician’s medical specialty] [Physician’s NPI]\n[Physician’s practice name]\n[Phone #] [Fax #]\nEncl: [Medical records, photo(s), Letter of Medical Necessity, statement of financial hardship, case number, written response to denial]\nNPI, National Provider Identifier\n*Include patient’s medical records and supporting documentation, including clinical evaluation, scoring forms, and photos of affected areas.\n†Identify drug name, strength, dosage form, and therapeutic outcome.","cbCaiuuNvyCfjBfq","https://ap.wps.com/l/cbCaiuuNvyCfjBfq","docx",31535,"English","# Tiering Exception Request\n## Patient and Prescription Details\n## Clinical Rationale and Prior Treatment History\n## Unresolved Symptoms\n## Medical Records and Enclosures\n## Financial Burden and Summary\n## Physician Contact and Signature","[{\"question\":\"What information is required to identify the patient and prescription for a tiering exception request?\",\"answer\":\"The letter template requests the patient’s name and health plan membership, plus the product name, dosage, and frequency. It also includes the diagnosis and ICD code(s).\"},{\"question\":\"How should the clinician explain why the requested product is medically necessary?\",\"answer\":\"The letter asks the clinician to state that the product is medically appropriate and necessary and to request preferred access. It also provides space to explain why lower-tier formulary drugs would not be as effective and how the requested medication helps treat the condition.\"},{\"question\":\"What supporting documents should be enclosed with the tiering exception letter?\",\"answer\":\"The template specifies enclosing copies of medical records and a Letter of Medical Necessity, along with items listed under enclosures such as financial hardship statements, case number, and any written response to denial. It also notes including clinical evaluation and supporting forms or photos when applicable.\"}]","Tiering Exception Letter Sample Template | DOCX"]