Formulary Exception Request
Depending on the nature of your request, Pharmacy Services may need to obtainadditional information. If the therapy requested is not well established, references are helpful. The completeness of the information you provide has an impact on howquickly your request can be considered. Thank you.
Name of Requesting Practitioner
*
Requesting Practitioner's NPI #
*
Requesting Practitioner's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Requesting Practitioner's Fax Number
Please enter a valid fax number.
Format: (000) 000-0000.
Contact Name
*
Practitioner's Location (i.e. Capitol Clinic, Wingra, UWHC)
*
Patient's Name
*
Patient's GHC-SCW Member Number
*
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Name of Drug You Are Requesting Insurance Coverage For
*
Date of Request
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
REASON
(Please check one and provide requested information)
Formulary Drugs have been Tried and Failed Due To:
*
Therapeutic Failiure
Adverse Effects
Other
Patient's Diagnosis
*
Reason/Explanation for Request
*
Please list Patient’s Medication History, and indicate the results, including dosage and duration of therapy.
Rows
Medication
Results
Dosage
Duration of Therapy
Submit
Should be Empty: