Form Frx001 - Tier Exception Request Form

FORM # FRX001

Tier 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 tier exception:

_______________________________________________________________________________

2. The patient is unable to take the drug at the lower tier because:

The lower tier drug is not as effective as the requested drug

Adverse events

Contraindication

Drug failure

Medically necessary

Other:________________________________________________________________

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

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