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Your 2020 Formulary
Jan 1, 2020 What is a formulary? A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen.
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Formulary Exception/Prior Authorization Request Form
PRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED, TO EVALUATE REQUESTS. PLEASE FAX COMPLETED FORM TO 1-888-836-0730. I
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Medical Exception/Prior Authorization/Precertification
Medical Exception/Prior. Authorization/Precertification*. Request for Prescription. Medications. Fax this form to: 1-877-269-9916. OR. Submit your request
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