Medication Exception Request Form
Member Information
Member Full Name (required)
Member Date of Birth (required)
Member ID (required)
Member Email (required)
Member Phone Number (required)
Member Full Address (required)
Are you requesting this for yourself or someone else?
For myself
For someone else
Requester Information, if not the Member
Requester Name
Relationship to Member
Requester Phone Number
Requester Email
Requester Full Address
Provider Information
Provider Name (required)
Provider Address (required)
Provider Phone Number (required)
Provider Fax Number (required)
Provider NPI Number
Drug Information
Drug Name (required)
Drug Strength (required)
Drug Quantity Per Month (required)
Please include additional information here
If this is an urgent request, check this box for a faster review
The text you enter here is displayed at the end of the form.
