Formulary Exception Request

This form may be used to request exceptions from the drug formulary, including drugs requiring prior authorization. Please note that the prescription benefit and/or plan contract may exclude certain medications.

*If the requested drug is a specialty medication and it is approved, THP Rx will notify you in the approval letter of which specialty pharmacy to use (does not apply to Medicare members).

If you, or prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life or health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or in a telephone call to us) that he or she agrees that waiting 72 hours could seriously harm your life or health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician’s support, we will decide if your health condition requires a fast decision. Members may be responsible for copayments. Contact The Health Plan to initiate an exceptions request either by phone at 1.800.624.6961, ext. 7914, email at pharmacyservices@healthplan.org.

Member Information

Today's Date:

Americas/New York

Member Name: Required

Member DOB:

Americas/New York

Member ID #: Required

Member Weight:

Member Height:

Medication Information

Name of prescription drug: Required

Diagnosis Code:

CPT Code:

Reason formulary agents are not appropriate: Required

Medications tried in the past:

Risk to formulary alternatives:

Pertinent Labs:

Physician Information

Physician Name: Required

Medical Specialty:

NPI ID #:

Office Address

Address 1 Required

Address 2 Required

City Required

State Required

Postal Code Required

Phone Number: Required

Fax Number: Required

Office Contact Person: Required

Title of Office Contact Person: Required

Expedited Request

Complete this section only if you are requesting an urgent decision

If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life or health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or in a telephone call to us) that he or she agrees that waiting 72 hours could seriously harm your life or health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician’s support, we will decide if your health condition requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.

CHECK THIS BOX IF YOU NEED A DECISION WITHIN 24 HOURS:

I need an expedited coverage determination.

Requestor's Signature:

Requestor's Relationship to Member:

Requestor's Phone Number: