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(1) Dosage Form(S) And/Or Dosage(S) Tried;
Web to submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., hcr), please contact the optumrx® pa department through telephone. (2) explain medical reason] ☐ request for formulary tier. Just complete this form and submit the pharmacy receipts showing the amount you paid at the. 2016 2nd edition 5 the information contained in this document is proprietary and confidential to optumrx.