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Member Initiated Formulary Exception Request

If you need a non-formulary drug, you may ask for an exception request for a non-formulary prescription drug. This process may permit coverage for those drugs designated as “non-formulary” and not included in the member’s drug coverage list. Note: This request is different than a prior authorization request which allows Wellmark to verify a prescription drug included on the member’s formulary drug list is part of a specific treatment plan and is medically necessary.

 

To begin the Formulary Exception Request process:

  1. Complete the member portion of the Exception Request for Non-Formulary Prescription Drugs #P-23282 pdf and forward the form to the prescribing provider.
    or 
    Contact Wellmark Customer Service at the number printed on the back of your ID card.
  2. The prescribing provider will complete his/her section, then fax the completed form to the numer on the form.
  3. If Wellmark receives an incomplete form that does not provide sufficient information to support the need for the non-formulary drug, the formulary exception request cannot be evaluated. Providers will be asked to resubmit a complete formulary exception request form with required documentation to Wellmark so the request can be reviewed and a decision can be made.
  4. If the exception request is denied, a letter will be sent to the prescribing provider and the member.

If the initial formulary exception request is denied and you do not agree with our decision, you may request an independent review of the exception request. If the member would like the provider to request an independent review of the exception request, a Personal Representative Appointment and Authorization to Release Protected Health Information form pdf must be completed.

 

Details regarding the independent review process for formulary exception requests will be provided in the denial notification letter for the initial request. Note: Should the member or the provider choose to request an independent review of the formulary exception and the decision is made to uphold the denial, the decision is final and no other steps can be taken for coverage of the requested drug as a benefit of the member’s plan. It will not be eligible for appeal.  



Related Information
»   Locate a Pharmacy open new window image
»   Download Forms
»   Prior Authorization and Quantity Limits
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