How can you request an exception to the Plan's formulary?
You can ask us to make an exception (Prior Authorization) to our coverage rules. We will need to work with your prescriber to obtain additional information to support your request. There are several types of exceptions that you can ask us to make.
You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Highest Tier Name drug, you can ask us to cover it as a Lower Tier Name instead. This would lower the co-payment amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.
To request an exception, you or your appointed representative should call Presbyterian Customer Service Center at 505-923-6060 or toll free at 1-800-797-5343 or TTY users should call 711, Monday through Sunday 8 a.m. to 8 p.m. You, your doctor or pharmacist can also fax a request to: 505-923-5540 or exception requests may be mailed to:
PHP Pharmacy Department
P.O. Box 27489
Albuquerque, NM 87125-7489
Form Requesting Prior Authorization for Drugs
For information on Appeals and Grievances, click here