Form Frx004 - Formulary Exception Request Form

FORM # FRX004

Formulary Exception Request Form

Member Information

Provider Information

Patient Name ____________________________

Provider Name _____________________________

Cardholder ID ___________________________

DEA Number ______________________________

Date of Birth ____________________________

Address ___________________________________

Address ________________________________

City, State and Zip ___________________________

City, State Zip ___________________________

Phone Number ______________________________

Phone Number ___________________________

FAX Number _______________________________

Pharmacy Information

Pharmacy Name___________________Address__________________Phone______________________

Criteria for Approval:

1. Name of the drug requested:__________________________________________________________

2. What is the diagnosis of the patient?___________________________________________________

3. The patient is unable to take the drug(s) on formulary because:

Adverse events

Contraindication

Drug Failure

Formulary drug not as effective

Formulary changes

Patient already on requested drug

Other:

___________________________________________________________________________

___________________________________________________________________________

4. Anticipated length of therapy: Check One: 30 day supply _______ Number of months___________

Provider Signature _________________________________________ Date ________________________

Fax completed forms to (866) 284-4509.

For Office Use Only

Date/Time Received_____________________________________________________________________

Reference Number______________________________________________________________________

Approved / Denied (Circle One) by _____________________________ Date_______________________

Date/Time Returned to Provider___________________________________________________________

_____________________________________________________________________________________

If you have any questions regarding this form, contact the Prior Authorization Department Toll Free at

(866) 284-4492 or FAX Toll Free at (866) 284-4509.

FOX Rx Care Utilization Management

3375-I Capital Circle NE

Tallahassee, FL 32308

IMPORTANT NOTICE: This facsimile is intended to be delivered to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from

disclosure and applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number

set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by other than the named addressee, except by

express authority of the sender to the named addressee.