Get the free Non-Formulary Form

Non-Formulary Form IF THIS IS AN URGENT REQUEST, Please Call UPMC Health Plan Pharmacy Services. Otherwise, please return completed form to: UPMC HEALTH PLAN PHARMACY SERVICES PHONE 800-979-UPMC (8762)

How to fill out non-formulary form

1. To start filling out a non-formulary form, gather all the necessary information and documentation that may be required. This could include details about the medication in question, such as its name, dosage, and therapeutic alternatives.
2. Next, carefully review the instructions provided on the non-formulary form. Ensure that you understand the specific requirements and any supporting documents that may be needed to complete the form accurately.
3. Begin filling out the form by inputting your personal information, such as your name, contact details, and any relevant identification numbers. Double-check the accuracy of these details to avoid any potential errors.
4. Provide the details about the prescribed medication that is not covered under the formulary. Include the medication's name, dosage, frequency, and the reason why the non-formulary request is necessary. Be concise but provide enough information to support your case.
5. Attach any necessary supporting documents that may strengthen your non-formulary request. These documents could include medical records, test results, or a letter of medical necessity from your healthcare provider. Ensure that all attached documents are labeled appropriately and securely attached to the form.
6. Once you have completed filling out the non-formulary form and attached any required documentation, review the entire form for accuracy and completeness. Look for any mistakes or missing information that may hinder the processing of your request.
7. If applicable, make a copy of the completed form and attached documents for your own records. This way, you have a backup in case the original form gets lost or misplaced during the submission process.

Who needs a non-formulary form?

1. Individuals who have been prescribed a medication that is not included in their insurance plan's formulary may need to fill out a non-formulary form. This form allows them to request consideration for coverage or an exception on the grounds of medical necessity.
2. Patients who have tried and failed alternative medications listed on the formulary may require a non-formulary form. This is typically the case when no suitable therapeutic alternatives are available, and the prescribed medication offers the most effective treatment option.
3. In some cases, healthcare providers may also need to complete a non-formulary form on behalf of their patients. This is common when a medication is medically necessary but not covered under the insurance plan's formulary.

Remember to consult with your healthcare provider or insurance provider for specific guidelines and instructions on filling out a non-formulary form, as these may vary depending on the organization and their policies.

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What is non-formulary form?

Non-formulary form is a document used to report information that is not included in the standard formulary.

Who is required to file non-formulary form?

Entities or individuals who have information that is not included in the standard formulary are required to file a non-formulary form.

How to fill out non-formulary form?

To fill out a non-formulary form, provide the required information in the designated fields and submit the form according to the instructions provided.

What is the purpose of non-formulary form?

The purpose of non-formulary form is to ensure that all relevant information is reported, even if it is not included in the standard formulary.

What information must be reported on non-formulary form?

All information that is not included in the standard formulary must be reported on the non-formulary form.