Blue Cross Blue Shield Formulary E Ception Form

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This fax machine is located in a secure location as required by hipaa. To submit request electronically, please go to covermymeds.com using plan/pbm name “bcbs nc” tier exception. See section on individual see section on.

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(incomplete form may delay processing) please return completed form to: Please consult your plan brochure for formulary coverage. To submit request electronically, please go to providerportal.surescripts.net/providerportal/login or. Fax or mail the completed form to bcbsma..

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(Incomplete Form May Delay Processing) Please Return Completed Form To:

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Web The Formulary Exception Form Is Included As Part Of This Document For Physicians To Submit For Patients.

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