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 PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) requests
- Medicare Part D Adcirca™/Revatio® Physician Fax Form
- Medicare Part D Aldara®/Zyclara® (imiquimod) Physician Fax Form
- Medicare Part D Ampyra® Physician Fax Form
- Medicare Part D Arcalyst® Physician Fax Form
- Medicare Part D Biologic Agents Physician Fax Form
- Medicare Part D Erythropoietin Stimulating Agents Physician Fax Form
- Medicare Part D Fentanyl Oral Physician Fax Form
- Medicare Part D Forteo® Physician Fax Form
- Medicare Part D Growth Hormone Physician Fax Form
- Medicare Part D Immune Globulin Physician Fax Form
- Medicare Part D Incivek®/Victrelis® Physician Fax Form
- Medicare Part D Kuvan® Physician Fax Form
- Medicare Part D Nplate®/Promacta® Physician Fax Form
- Medicare Part D Multiple Sclerosis Physician Fax Form
- Medicare Part D Noxafil®, Vfend®, voriconazole Physician Fax Form
- Medicare Part D Oral Oncology Agents Physician Fax Form
- Medicare Part D Nuvigil®/Provigil® Physician Fax Form
- Medicare Part D Peginterferon (Hepatitis C) Physician Fax Form
- Medicare Part D Relistor® Physician Fax Form
- Medicare Part D Sensipar® Physician Fax Form
- Medicare Part D Xenazine® Physician Fax Form
- Medicare Part D Xolair® Physician Fax Form
- Medicare Part D Xyrem® Physician Fax Form
Forms for Prepaid Medical Assistance Program (PMAP), MinnesotaCare, Minnesota Senior Care Plus (MSC+), and Special Needs BasicCare (SNBC) requests
- Antifungal Agents (Lamisil®, Sporanox®, terbinafine) Prior Authorization Physician Fax Form
- Growth Hormone Prior Authorization Physician Fax Form
- Forteo® Prior Authorization Physician Fax Form
- Peginterferon (Hepatitis C) Prior Authorization Physician Fax Form
- Xolair® Prior Authorization Physician Fax Form