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Request for Prescription Drug Coverage Exception

Please complete this form if you are submitting an initial determination or exception request. Click the submit button to send this form. Please note: if you are appealing a previous adverse decision, call the number on the back of your ID card.

Note that changes made to your information on this form will not save to your account. To update your information permanently, please sign in and go to Manage My Account.

Member's Information (as it appears on the member's ID card)

Name of Prescription Drug you are Requesting (if known, include strength and quantity requested)


Name of condition
Prescribing Physician Information


Type of Exception Request

Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.

Please select the option below that best describes your request
If you, or your prescribing physician, believe that waiting for a standard decision could seriously harm your life or health or ability to regain maximum function, you can ask for and we will give you an expedited (fast) decision.