Formulary Exception Request
This form may be used to request exceptions from the drug formulary, including drugs requiring prior authorization. Please note that your prescription drug rider 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 email@example.com.
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.