Please select all of the statements that apply to this request:
Please select one or more of the statements below.
* Please note: If you are asking for a formulary or tiering exception, your prescriber must provide a statement supporting your request.
Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information.
Your prescriber may use the attached "Supporting Information for an Exception Request or Prior Authorization" to support your request.