Presbyterian Health Plan Pharmacy Exception

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Pharmacy Exception Criteria

• Pharmacy Exception Criteria for all Plans

Pharmacy Exception forms

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

• Pharmacy Exception Process form for all Product Lines
• Tiering Exception Process form - Medicare Part D
• Oral Nutrition for Presbyterian Salud
• Diapers for Presbyterian Salud
• Weight Loss Form (Not a covered benefit for Medicare Part D)
• Zostavax Form

Pharmacy Exception Forms for the Walgreens-Provided Specialty Pharmaceuticals

• Injectable Drug Request Form
• Xolair Form