Coverage Exception Request

Use this form to submit an Exception Request for a drug administered by a physician

This means your physician will provide the drug in the office and includes any drug considered non-self-administered or “bought and billed” by a physician. For exceptions to drug formularies (drugs obtained through a pharmacy), please visit professionals.optumrx.com

Physician-Administered Drug Exception Request

* indicates a required field.

Urgency of Request

Check One *

Standard decision (3 Business Days)

Fast decision (1 Business Day)

Member Information

Member Name *

Member Address *

City *

State *

Zip Code *

Member ID # *

Member Date of Birth *

Physician Information

Prescribing Physician *

Physician Address

City

State

Zip Code

Phone Number

Fax Number

NPI/DEA Number

Prescription Information

Medication Name/Dosage *

Reason(s) for use/Directions *

Please provide your Electronic Signature before you submit this form

Electronic Signature *

Today's Date *

Intended use must be in accordance with FDA indications or supported by approved CMS Compendia.

In order to be approved, intended use of the requested drug must be in accordance with indications approved by the FDA and supported by approved CMS Compendia. Additionally, rationale must be supplied for the use of the non-covered drug versus the covered alternative(s). It must be demonstrated with supplied medical chart notes that there is high likelihood of an efficacy, tolerability, or safety advantage with the non-covered drug versus the covered alternatives. It must be demonstrated that covered therapeutic alternative medications have been tried, or that use of these medications would likely result in a poor outcome for the patient.

COVERAGE EXCEPTION REQUEST