NOTE: If you are not the member or the member's prescribing physician or other prescriber, you must fax a signed Appointment of Representative form (or equivalent notice) to 1-800-693-6703 (toll free). You can also attach the signed Appointment of Representative form below. For more information on how to appoint a representative, please refer to your plan benefits materials.
If you are asking for a formulary or tiering exception, your PRESCRIBING PHYSICIAN must provide a statement to support your request.
You cannot ask for a tiering exception for a drug in the plan's Specialty Tier. In addition, you cannot obtain a brand name drug at the copayment that applies to generic drugs. See your benefit materials for more information.