How to Fill Out and Submit the FEP Formulary Exception Form

To request coverage of a drug that isn’t on your plan’s list, download the drug-specific FEP formulary exception form (labeled as a Prior Approval form) from the CVS Caremark FEP portal, complete the member section yourself, have your prescriber complete and sign the provider section with clinical justification, and submit it — electronically through your doctor’s office if possible. There is no single universal form; CVS Caremark publishes a separate prior approval form for each medication that requires one.¹

Find the Form for Your Specific Drug

Every medication that requires prior approval has its own PDF with clinical questions tailored to that drug. A blank one-size-fits-all form does not exist. Go to info.caremark.com/dig/fep-pa, select the first letter of your medication’s name, expand the listing, and download the PDF for that drug.¹ The portal hosts forms for more than 200 medications.

The formulary exception process itself is described on fepblue.org’s Claim Forms page, which notes that it “allows members to apply for coverage of a non-covered drug if they have tried and failed the covered drug(s).”² The downloadable forms live on the Caremark portal, along with supplemental PDFs — a step therapy and quantity limits list, an autoimmune agents formulary exception list, and a list of other products requiring formulary exceptions.¹

A prior approval or formulary exception request applies when the prescribed drug is off-formulary, is subject to step therapy, has quantity limits, or falls outside standard FDA-approved usage.¹

Complete the Member Section

The top portion of the form is yours. You enter your name, date of birth, contact information, and your consent for the release of medical records related to the request.

The critical field is your FEP member ID, which begins with the letter “R” followed by eight digits and appears on the front of your member card.³ A missing or wrong ID number is one of the fastest ways to get a request bounced administratively, before any reviewer looks at the clinical case. Double-check it against your card.

Have Your Prescriber Complete the Provider Section

The lower portion belongs to your prescribing physician. Because each form is drug-specific, the questions differ — an opioid form asks different things than a biologic form. In general, your doctor needs to provide:

The exact medication name matching the FDA-approved label, dosage, strength, and expected duration of treatment.
The diagnosis being treated, typically with an ICD code.
Clinical justification for why this drug is needed rather than a formulary alternative.
Step therapy history: which covered alternatives were tried, how long each was used, and why each failed — side effects, lack of effectiveness, or both.
Any contraindications: drug interactions, allergies, or coexisting conditions that make formulary alternatives unsafe.

The provider must sign the form. An unsigned form is returned without review.

What Makes the Clinical Case Strong

A vague preference for one drug over another rarely results in an approval. Reviewers at CVS Caremark are evaluating whether the requested medication is the only safe and effective remaining option, and that standard needs concrete evidence.

The strongest requests document a clear trail of failed alternatives. For each formulary drug tried, the record should show how long you took it, what happened (worsening symptoms, allergic reaction, intolerable side effects), and when your doctor stopped it. Lab results that quantify a lack of response carry more weight than a note simply saying the patient did not respond.

If the reason is a contraindication rather than a failed trial, your doctor should explain the specific mechanism: the documented allergy, the interacting medication, the coexisting condition. Attach supporting documentation directly to the form — lab results, specialist notes, allergy records, relevant history. The aim is to leave the reviewer with no reasonable alternative to approve.

Submit the Form

Three submission methods are available, and the speed difference between them is significant.

Electronic Prior Authorization

The fastest route is electronic prior authorization (ePA), where your doctor submits through a web portal or their electronic health record system. ePA uses automated scoring and can deliver a decision in minutes to hours.¹ The digital questions also reduce the missing-information back-and-forth that slows paper submissions. If your doctor’s office regularly handles prior authorizations, ask whether they use ePA. It can be the difference between a same-day answer and a multi-day wait.

Fax

For paper-based offices, the completed form and any attachments can be faxed. Each drug-specific form prints its fax number in the upper right corner. Based on FEP prior approval forms, the fax number is 1-877-378-4727, with the FEP Clinical Call Center reachable at 1-877-727-3784 for phone-based requests. Confirm the number on the form you downloaded, as it may vary. Fax and phone submissions typically take 16 hours to 3 days for a determination.¹

Mail

The form can also be mailed to the address printed in the upper right corner. Mail adds transit time on top of processing, so treat it as a last resort. Every page — including attachments — needs to arrive legible and complete; a missing page restarts the process.

Whatever the method, the provider’s office is responsible for transmitting the full package. You can track the status of a submitted request through the FEP Blue member portal under “Manage My Prescriptions.”¹

If It’s Urgent

If your physician indicates that a delay could seriously harm your health, ask them to flag the submission as urgent when contacting the Clinical Call Center at 1-877-727-3784. Combined with ePA, that’s the fastest available path.

How You’ll Hear Back

ePA requests are often resolved within hours. Fax and phone submissions generally produce a decision within 16 hours to 3 days.¹ Both you and your prescribing doctor receive notification. A written determination letter is mailed to your address on file explaining the approval, or the specific clinical criteria that were not met. Decision letters and status are also viewable through the FEP Blue portal or mobile app.

If Your Request Is Denied

A denial is not the last word. FEP has a multi-step disputed claims process, and denials are sometimes overturned when the record is filled in.

Ask FEP to Reconsider

Write to FEP within six months of the denial asking them to reconsider. The letter should explain why you believe the denial was wrong, referencing specific benefit provisions in the Service Benefit Plan brochure. Include copies of supporting documents: physician letters, medical records, lab results, and the explanation of benefits (EOB). Send it to the address on your EOB.⁴

Plan Review Timeline

For a post-service claim, FEP has 30 days from receiving your request to pay the claim, uphold the denial in writing, or ask you or your provider for more information. If they request more information, you have 60 days to provide it, and FEP then has another 30 days to decide.⁴

Escalate to OPM

If FEP upholds its denial after reconsideration, you can escalate to the U.S. Office of Personnel Management. Write to OPM within 90 days of FEP’s letter upholding the denial. If FEP never responded to your reconsideration request within 30 days, or never sent a decision within 30 days of receiving additional information, the deadline extends to 120 days.⁴

Send the appeal to: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Health Insurance 1, Room 3425, 1900 E Street NW, Washington, D.C. 20415-3610.⁴ Include a statement explaining why FEP’s decision was wrong (citing brochure provisions), copies of all correspondence with FEP about the claim, supporting medical records, your daytime phone number, and your email address if you want OPM’s decision electronically.

If your first request is denied, work with your doctor to submit a reconsideration that directly addresses the specific clinical criteria the denial letter says were not met. That focused response, more than a longer general letter, is what tends to change the outcome.

1
Caremark. Prior Approval – Federal Employee Program – CVS Caremark
2
Blue Cross and Blue Shield Federal Employee Program. Claim Forms
3
Blue Cross and Blue Shield Service Benefit Plan. Service Benefit Plan Member ID Card Quick Reference Guide
4
Blue Cross and Blue Shield’s Federal Employee Program. Dispute Claim