Exception Process – 2025 Core NH 5-Tier | OptumRx

You can ask for an exception if you need a medication that isn’t covered or has quantity limits. Drugs that aren’t listed on your plan’s formulary (prescription drug list) are not covered. We will grant exceptions only for clinical reasons.

Your provider can start the exception process by completing a formulary exception request form and faxing it to 1-617-673-0988. They can also call Provider Services at 1-800-708-4414.

Call Member Services at 1-888-333-4742 (TTY: 711) if you have questions about the status of your exception request. 

Harvard Pilgrim Medication Request Form (PDF)

MA Standard Medication Request Form (PDF)

NH Standard Medication Request Form (PDF)

MA Standard Request Form for Chemotherapy and Supportive Care (PDF)