Formulary Tier Exception Member Request Form (English)
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1Send completed form to:
Service Benefit Plan
Attn: Reconsideration
Formulary Tier Exception
P.O. Box 52080
Member Request Form
Phoenix, AZ 85072-2080
FAX: 1-800-273-5357
CARDHOLDER OR PHYSICIAN COMPLETES
• If you are requesting a copay exception for more than one medication, please use a separate form for each medication.
Date: ____ / ____ / ______
Patient Name: ________________________ / ______ / ___________________________________
First
MI
Last
Patient Address
Street Address
City
State
Zip
Patient Date of Birth: ____ / ____ / ____
Sex: M_____ F
_____
R
Cardholder Identification Number
STANDARD OPTION/BASIC OPTION MEDICARE B PRIMARY MEMBERS ONLY: If approved, your
exception override will be applied either to the retail pharmacy OR the mail service pharmacy – please indicate
where you would like to obtain your medication.
Retail Pharmacy
Mail Service Pharmacy
PHYSICIAN ONLY COMPLETES
All fields below must be completed to begin processing the Formulary Tier Exception request.
Patient’s Diagnosis: ______________________________________________________________________________
Brand-Name Drug copay request for (please specify drug name): _________________________________________
Please specify Dosing Directions
: _______________________________________________________________________
Indicate the outcome that best describes your patient’s experience with all drugs in this therapeutic class:
Therapeutic Failure(s) with generic and/or brand medications in this therapeutic class.
1) Indicate ALL the drug name(s) the patient has failed on in this class: __________________________________
_____________________________________________________________________________________________
2) Describe the therapeutic failure(s): _____________________________________________________________
_____________________________________________________________________________________________
Adverse Event(s) with generic and/or brand medications in this therapeutic class.
1) Indicate ALL the drug name(s) the patient has had an adverse event within this class: _____________________
______________________________________________________________________________________________
2) Describe the adverse event(s): __________________________________________________________________
__________________________________________________________________________________________
__________________________________________
( ______ ) _____________________
( ______ ) _____________________
Physician Name (Print Clearly)
Phone
Fax
______________________________________________
______________________________
__________
______________
Street Address
City
State
Zip
____________________________
_____________________________________________
________ / ________ / ________
Prescriber’s NPI
Physician Signature
Date
P
rescriber Certification: I certify that I am the physician and all information provided on this form to be true and correct to the best of my knowledge and belief.
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