Form Frx002 - Expedited Formulary Exception Request Form

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FORM# FRX002
Expedited 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 for the expedited request: ___________________________________________
2. What is the diagnosis of the patient?_________________________________________________
3. Will applying the standard timeframe of 72 hours seriously jeopardize the life or health of the
member or the member’s ability to regain maximum function?
Yes
No
4. If answered Yes to question 3, please describe how the life or health of the member or the
member’s ability to regain maximum function may be jeopardized.
_______________________________________________________________________________
_______________________________________________________________________________
(May send any additional documentation to support this request.)
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.

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