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
Required
Required
Member Address
Required
Physician Information
Required
Physician Address
Required
Medication Information
Required

(including strength, quantity and quantity requested per month)

Required
Expedited Request
Signature

(ex. member, family, physician, power of attorney)

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