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Pharmacy Exceptions

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.

If your drug is in Tier 4, Non-Preferred Drugs, you can ask us to cover it at the lower cost-sharing amount that applies to drugs in Tier 3, Preferred Brand. This would lower the co-payment amount you must pay for your drug. You cannot ask us to change the cost-sharing tier for any drug in Tier 5 Specialty Drugs.

To request an exception, you or your appointed representative should call Presbyterian Customer Service Center.

505-923-6060 or 1-800-797-5343 (TTY 711)
Hours: 8 a.m. to 8 p.m., 7 days a week*

You, your doctor or pharmacist can also fax or mail an exception request.

Fax: 505-923-5540

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

*Hours February 15 to September 30 are 8 a.m. to 8 p.m. Monday through Friday (except holidays).


Last Updated: 09/30/2017