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 (nonformulary) 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

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.

Fields listed with an * are required.

Required *

  • * Member Name 
  • Date of Birth
  • * Member ID 
  • Requestor's relationship to member (ex.: member, family, physician, power of attorney)
  • Address
  • City
  • State
  • ZIP Code
  • * Phone Number 
  • * Name of prescription drug you are requesting (including strength, quantity and quantity requested per month) 
  • * Reason formulary agents are not appropriate (include diagnosis, medications tried in past and/or risk to alternatives) 
  • * Prescriber Name 
  • NPI #
  • Medical Specialty
  • Prescriber Address
  • Prescriber City
  • Prescriber State
  • Prescriber ZIP Code
  • * Prescriber Phone Number 
  • Prescriber Fax Number
  • Office Contact Person
Expedited Request
  • I need an expedited coverage determination.
  • Beneficiary/Requestor's Signature
  • Date