You can request an exception.
Providers, members, and member representatives can ask us to make an exception (prior authorization) to our coverage rules. We will work with the prescriber to get additional information to support the request. There are several types of exceptions that can be requested.
- 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.
Refer to your member handbook for more information about exceptions and the prior authorization process.
How to request an exception.
To request an exception, you or your appointed representative should call the Presbyterian Customer Service Center at the number listed on the back your ID Card.
You, your doctor, or pharmacist can submit a request by fax or mail.
Fax:
Mail:
PHP Pharmacy Department
P.O. Box 27489
Albuquerque, NM 87125-7489
If you are a Medicare Advantage member, visit your plan specific website
Prior Authorization Request Processing Times
Standard Pharmacy PA Requests: When all necessary information is provided with the Drug PA request, standard requests are processed as expeditiously as the member’s health requires, within
72 hours after the request is received.
Expedited Pharmacy PA Requests: When a member or their provider believes that waiting for a decision under the standard time frame could place the member’s life, health or ability to regain maximum function in jeopardy, a PA can be expedited. These requests are processed within
24 hours after the request is received.
If additional information is required in order to decide on a PA, Presbyterian Pharmacy Services will contact your prescriber by phone and, if necessary, by fax.
Once a decision has been made, you will receive a notification with either an approval or adverse determination.
Learn more about Presbyterian's Nondiscrimination Notice and Interpreter Services