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Brand penalty exception form 2026

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The document is a Brand Penalty Exception Request form that allows prescribers to request approval for a patient to receive a brand-name drug instead of a generic alternative, ensuring the patient pays only the brand copayment. It requires detailed patient and prescriber information, along with specific clinical justifications for the request, such as inadequate response to the generic or allergies. The form must be completed accurately to avoid processing delays.

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Click ‘Get Form’ to open the brand penalty exception request in the editor.
Begin by filling out the Patient Information section. Enter the patient's name, date of birth, and Plan Member ID Number.
Next, complete the Prescriber Information section. Input the prescriber's name, phone number, and fax number.
In the Brand Drug Name field, specify the requested brand-name drug along with its strength and dosage form.
Provide a diagnosis for the patient that justifies this request.
Answer each of the three questions regarding treatment response and appropriateness of generic alternatives. Be sure to document any specific clinical concerns as needed.
Finally, ensure that the prescriber signs and dates the form before submitting it. Fax it to the Exceptions Department at 1-888-487-9257.

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