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Pharmaceutical Exception Request Form - 508 Pharmaceutical Exception Request Form - 508

Pharmaceutical Exception Request Form - 508 Pharmaceutical Exception Request Form - 508 2026

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The document is a Pharmaceutical Exception Request form that allows members to request exceptions for non-covered drugs, copay waivers for brand name contraceptives, or expedited reviews. It requires completion by a physician and includes sections for member and prescribing practitioner information, medical conditions, medication history, and submission instructions. Additionally, it contains a nondiscrimination notice outlining the rights of individuals regarding civil rights laws.

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Click ‘Get Form’ to open the Pharmaceutical Exception Request Form - 508 in the editor.
Begin by indicating the type of exception request. Check one of the options: Non-Covered Drug only, Waive Copay for Brand Name Contraceptive, or Request for Expedited Review.
Fill in the DATE field and specify the DRUG REQUESTED. Remember, only one drug per request is allowed.
Enter the QUANTITY PRESCRIBED and complete the MEMBER section with your details including Member ID No, DOB, and Office Phone No.
In the PRESCRIBING PRACTITIONER section, provide the practitioner's name and contact information including Office Fax No.
Detail the medical condition related to the drug requested and expected duration of treatment. Include reasons for any copay waiver if applicable.
List any previous or current medications related to your medical condition in the MEDICATION HISTORY section, ensuring to include treatment dates.
Once completed, submit your form via fax or email as indicated at the bottom of the document.

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2020	4.8 Satisfied (25 Votes)
2015	4.2 Satisfied (48 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How hard is it to get a formulary exception?

you have pretty good odds of getting the formulary exception approved when it is a continuation of therapy (in your case) vs a new therapy. they will just have to document what youve tried and failed, and how what youre on now is working well for you and usually it is approved when you are already on the medication.

What does exempted mean in pharmacy?

Exempt drug means a drug on the MTUS Drug List which is designated as being a drug that does not require authorization through prospective review prior to dispensing the drug, provided that the drug is prescribed in ance with the MTUS Treatment Guidelines.

What is an exception in pharmacy?

Non-Formulary Drug Exception: A request to cover a non-formulary drug. Tier Exception: A request to cover a non-preferred drug at a lower tier cost share. Brand Exception: A request to cover a non-preferred brand drug at the applicable cost-share when a generic alternative is available.

What is a pharmacy exception?

An exception procedure can be used by prescribers and patients to request coverage for drugs that are not included on a plans drug formulary. Through this administrative process, a plan can agree to cover medically necessary nonformulary drugs on a case-by-case basis.

What is an exception of prescription?

Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollees prescriber must submit a supporting statement to the plan sponsor supporting the request.

What is pharmacy exception processing?

The exception process can be used to override benefit limits that are based on U.S. Food and Drug Administration (FDA)-approved durations of treatment or maximum dosing limits. A plan may limit drug benefit coverage to FDA-approved durations or dosing.

How do I request for Medicare prescription drug coverage determination?

MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION You may also ask us for a coverage determination by phone at 1-866-235-5660, (TTY: 711), 24 hours a day, 7 days a week, or through our website at .silverscript.com. Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf.

Pharmaceutical Exception Request Form - 508 Pharmaceutical Exception Request Form - 508 2026

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