Tip for Formulary Exception (insurer/PBM-specific)

Have your prescriber complete the form — formulary exceptions must come from the prescribing physician

Tip for Formulary Exception (insurer/PBM-specific)

Document all formulary alternatives that were tried and why they failed or are contraindicated

Tip for Formulary Exception (insurer/PBM-specific)

Request expedited review if the patient is currently without the medication and their health is at risk

InsurancehardDoctor signature required

Formulary Exception Request

Formulary Exception (insurer/PBM-specific) · Health Insurance Plans / PBMs

Request for coverage of a drug that is not on the plan's formulary. Prescriber must document why formulary alternatives are not appropriate for the patient due to medical necessity.

Form Details

Total fields: 12
Auto-fillable: 7 (58%)
Time without BeneFill: 25 minutes
Time with BeneFill: 7 minutes
Time saved: 18 minutes
Filled by: doctor
Frequency: as needed

Fill this form with BeneFill

Auto-fill 58% of fields from your profile. Save 18 minutes. Download a real PDF.

7 of 12 fields58% auto-filled

Start Filling Upload Your Copy Instead

Where to Submit This Form

📠

Fax to the insurer's pharmacy department or PBM

Fax number is typically on the formulary exception form or the insurer's provider portal.

🌐

Submit through the insurer's provider portal or PBM website

📬

Mail to the insurer's pharmacy prior authorization department

Filing Deadline

No strict filing deadline, but the patient cannot obtain the medication until the exception is approved. Standard decisions within 72 hours; expedited within 24 hours.

Required Attachments

📎 Prescriber's supporting statement documenting medical necessity
📎 List of formulary alternatives tried and failed (with dates and outcomes)
📎 Relevant medical records supporting the need for the specific medication
📎 Clinical literature supporting the requested drug (if applicable)

Processing Time

Standard: up to 72 hours. Expedited: within 24 hours if delay would jeopardize life or health.

What Happens Next

The insurer or PBM will review and issue a coverage determination. If approved, the drug is covered at the applicable formulary tier. If denied, you can appeal.

Tips for This Form

✓ Have your prescriber complete the form — formulary exceptions must come from the prescribing physician
✓ Document all formulary alternatives that were tried and why they failed or are contraindicated
✓ Request expedited review if the patient is currently without the medication and their health is at risk
✓ For Medicare Part D, the plan must provide a temporary supply while the exception is reviewed during transitions

More Insurance Forms

Medical Services Prior Authorization Request

PA Request (insurer-specific) · Health Insurance Plans

Request for approval of surgical procedures, imaging studies, specialist referrals, or other services requiring pre-authorization. Must demonstrate medical necessity.

Pharmacy Prior Authorization Request

Pharmacy PA (insurer/PBM-specific) · Health Insurance Plans / PBMs

Request for coverage of formulary drugs requiring PA, non-formulary drugs, or override of step therapy, quantity limits, or other utilization management edits.

Step Therapy Exception Request

Step Therapy Exception · Health Insurance Plans / PBMs

Request to bypass step therapy requirement and proceed directly to a preferred or non-preferred drug. Must document why first-step drugs are not appropriate for the patient.

Tiering Exception Request

Tiering Exception · Part D Plans / Commercial Insurers

Request to obtain a non-preferred drug at the lower cost-sharing tier. Prescriber must provide a supporting statement documenting why the lower-tier alternatives are not appropriate.

Specialty Drug Prior Authorization

Specialty PA (insurer-specific) · Health Insurance Plans / Specialty Pharmacies

Prior authorization request for high-cost specialty medications including biologics, gene therapies, and other complex drugs. Requires detailed clinical criteria documentation.

DME Prior Authorization Request

DME PA (insurer-specific) · Health Insurance Plans / Medicare MACs

Request for coverage of wheelchairs, CPAP machines, hospital beds, prosthetics, orthotics, and other durable medical equipment.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Health Insurance Plans / PBMs or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.