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Brand penalty exception form 2026
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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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