Formulary Exception Process
When a medication is prescribed that is not listed in the formulary, a Formulary Exception request is required. This process must also be followed for certain Pharmacy Utilization Management programs. Providers should complete the appropriate Formulary Exception or Utilization Management Form in these situations.
Forms for Medicare Part D requests
- 2010 Medicare Part D Adcirca™/Revatio® Physician Fax Form
- 2010 Medicare Part D Aldara® Physician Fax Form
- 2010 Medicare Part D Erythropoietin Stimulating Agents Physician Fax Form
- 2010 Medicare Part D Forteo® Physician Fax Form
- 2010 Medicare Part D Growth Hormone Physician Fax Form
- 2010 Medicare Part D Immune Globulin Physician Fax Form
- 2010 Medicare Part D Noxafil®, Vfend® Physician Fax Form
- 2010 Medicare Part D Oral Oncology Agents Physician Fax Form
- 2010 Medicare Part D Peginterferon (Hepatitis C) Physician Fax Form
- 2010 Medicare Part D Provigil® Physician Fax Form
- 2010 Medicare Part D Xenazine® Physician Fax Form
- 2010 Medicare Part D Xolair® Physician Fax Form
Forms for non-Medicare Part D requests