Presbyterian Health Plan Pharmacy Exception

You will need the free Adobe Acrobat Reader to open these files.

Pharmacy Exception Forms

Choose the appropriate form and print it out. Providers can also call (505) 923-5757 or 1-800-645-4347.

• Prior Authorization form for all Product Lines
• Diapers for Presbyterian Salud
• Oral Nutrition for Presbyterian Salud
• Suboxone/Subutex Form 
• Tiering Exception Process form - Medicare Part D
• Weight Loss Form (Not a covered benefit for Medicare Part D or Medicaid)
• Zostavax Form

Pharmacy Exception Forms for Specialty Pharmaceuticals

• Specialty Pharmacy Drug Request Form
• Xolair Form