Member Exception Request for Non-Formulary Medication

Member First Name:

Member Last Name:

Member Date of Birth:

CGHC Member ID:

Requesting Provider's First Name:

Requesting Provider's Last Name:

Requesting Provider's Phone Number

Requesting Provider's Fax Number

Medication Name:

Medication Strength:

Directions for Medication:

Please detail the reason for Exception Request:

WI-EXC-M-3304662