Presbyterian Health Plan Pharmacy Exception
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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
- Oral Nutrition Prior Authorization Form for Presbyterian Salud
- Suboxone/Subutex Form for Commercial and Medicare Plans
- Suboxone/Subutex Form for Salud and SCI Plans
- Disposable Diaper Prior Authorization Form for Presbyterian Salud
- 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
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