* Indicates a required field.

Request Date*
Member Information:
First Name *
Last Name *
MVP Member ID Number*
Date of Birth (MM/DD/YYYY)*
Address*
City*
State*
Zip*
Phone Number*

Exception Request Information:
Drug Requested (including drug strength)*
Directions for Use*
Reason for Requesting this Drug*
Provider Information:
Name*
Address*
City*
State*
Zip*
Phone Number*
Fax Number
NPI Number
DEA Number
Is this the first time you have used this medication or is it a continuation of therapy?*	First Time Continuation of Therapy
If this is a continuation of therapy, for how long have you been taking this medication?*
Have you spoken with your physician regarding this Request for medication?*	Yes No
Does your physician know that you are submitting this request?*	Yes No
What reasons are considered valid for requesting a Formulary exception? 1. The drug requires prior authorization. 2. Your physician has written a prescription for a dose and/or quantity that requires prior authorization. 3. You have a two-tier benefit plan (Child Health Plus) and the drug is non-Formulary. Requests for lower co-pays, vacation supplies, or early refills are not valid exceptions and therefore will not be reviewed. Certain medications may be excluded by your plan's prescription rider or plan contract. Submitting This Request 1.Email--select the Submit Request button at the top of the page. 2.Mail--print and mail the completed form to Attn: Pharmacy Dept., MVP Health Care, 625 State St., Schenectady, NY 12305. 3.Fax--1-800-376-6373. Allow up to 72 hours for MVP to process your request. If your request is urgent, contact the MVP Customer Care Center at 1-888-687-6277, Monday--Friday, 8 am--6 pm Eastern Time. MVP may require additional clinical information from your physician to process this request. The time frame for the review of this request will begin when MVP receives this information.