Grand Valley Health Plan - Choose Well
Home > Members > Prescription Drug Exceptions Process
DISCLAIMER:
  • Only complete the following form if you have received a coverage denial for a specific medication from GVHP.
  • We cannot process your request unless you complete the form in its entirety; including your name and a contact phone number where you can be reached.
  • Do not complete this form if you are requesting a refill on an existing prescription. This form should only be used if you are requesting a coverage exception for a drug GVHP has previously denied.
  • If you wish to refill an existing prescription, please choose the Prescription Refills option under the Members tab on the main menu.
  • Prescription information transmitted to and from the GVHP website is encrypted for your protection. However, the security of information transmitted through the Internet can never be guaranteed. Please take adequate steps to ensure that your information does not fall into the wrong hands.
I understand and agree to these terms.

Initiate a Prescription Drug Exception Request Form
Patient Information
Patient Name:
Contact Phone #:
Family Practice:
Prescription Information
Name of Medication Being Denied:
Reason for Denial:
Person Completing Form:
Relationshp to Patient: