Formulary Exception Request
This form may be used to request exceptions from the drug formulary, including drugs requiring prior authorization. Please note that your benefit and/or plan contract may exclude certain medications.
Should the prescribing physician decide that the original (non-formulary) drug is medically necessary, the physician or member may contact The Health Plan to initiate an exceptions request either by phone at 1.800.624.6961, ext. 7914 or via email at firstname.lastname@example.org.
For members, after submitting your form, The Health Plan will contact the prescribing physician on your behalf to provide a statement supporting your request within two business days. Once we receive the necessary information from your physician, you will be notified of the results within two business days.
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