Formulary Exception Requests

You can request a Formulary Exception if you want to receive a prescription drug that is not in Community Care’s Formulary or if it is on a different tier of the formulary (e.g., if you want a prescription drug where Community Care is providing a generic alternative).

You can request a drug coverage determination verbally to your Partnership Team or you make a written request. To help you provide necessary information, you can complete Medicare Part D Coverage Determination Request Form and mail it to Community Care.

Instructions for the Medicare Part D Coverage Determination Request Form

Use of this form is optional. The format and content of this form may be changed by any person or entity that uses it. If this form is used, Community Care may require additional information or documentation to support your request.

You can submit this form to Community Care by giving it to your Partnership Team or by mailing it to...

Community Care
Attn: Formulary Exceptions Request
1555 S. Layton Blvd.
Milwaukee, WI 53215

Toll Free: (866) 992-6600
TTY: (866) 288-9909