Request a Medication Exception Form

As a WellSense Health Plan member, you can use the form below to submit a prior authorization request for a prescription that is not currently covered by your plan. Please fill out the full form and hit "Submit" at the end. To confirm whether a drug is currently covered please visit the Drug Finder for your plan type.

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

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

Request a Medication Exception Form

Medication Exception Request

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