Get the free FORMULARY EXCEPTION PHYSICIAN FAX FORM

Este documento es un formulario que debe ser completado únicamente por el prescriptor para solicitar una excepción en el formulario médico. Incluye información del paciente y del médico, así

How to fill out formulary exception physician fax

How to fill out FORMULARY EXCEPTION PHYSICIAN FAX FORM

1. Obtain the FORMULARY EXCEPTION PHYSICIAN FAX FORM from your healthcare provider or the insurance company's website.
2. Fill in the patient's personal information, including name, date of birth, and insurance policy number.
3. Provide details of the prescribed medication, including the drug name, dosage, and prescribed quantity.
4. Include the reason for requesting the formulary exception, detailing why the patient requires this medication.
5. Attach any relevant medical documentation that supports the request, such as previous treatment history or clinical notes.
6. Ensure the form is signed and dated by the prescribing physician.
7. Submit the completed fax form to the appropriate fax number provided by the insurance company or pharmacy.
8. Follow up to confirm that the request was received and check the status of the exception approval.

Who needs FORMULARY EXCEPTION PHYSICIAN FAX FORM?

1. Patients whose prescribed medication is not covered under their current health insurance formulary.
2. Physicians who need to request a medication exception on behalf of their patients.
3. Pharmacists assisting patients who require non-formulary medications.

People Also Ask about

What do formulary exclusions mean?

Formulary exclusions are drugs that a PBM chooses not to be included in coverage. Usually, a PBM will contract with multiple insurance providers to manage their prescription benefits. A provider can choose not to follow their PBM's formulary exclusion list if they wish to cover a drug.

What if medication is not on the formulary?

A non-formulary drug refers to any medication that isn't included on your health insurance plan's formulary. These drugs are oftentimes not covered meaning that you will likely have to pay the full price unless you take steps to request coverage.

How to submit a formulary exception?

Your doctor is your ally on this. Most plans require that your doctor submit a formulary exception on your behalf. The doctor will need to send paperwork to your health plan indicating the reason that you can't take the preferred medications and must have one that is not currently on the formulary.

How to get Zepbound if not covered by insurance?

If you no longer have coverage, there are other savings options available to help support continued access to treatment: If you're looking for Zepbound without going through your health insurance, single dose vials (2.5 mg*, 5 mg, 7.5 mg and 10 mg) are available through LillyDirect Self Pay Pharmacy Solutions.

How do I request a formulary exception?

Your doctor is your ally on this. Most plans require that your doctor submit a formulary exception on your behalf. The doctor will need to send paperwork to your health plan indicating the reason that you can't take the preferred medications and must have one that is not currently on the formulary.

How to get a formulary exception for zepbound?

The request can be submitted by the prescriber via fax or, where available, through electronic prior authorization (ePA) beginning June 16, 2025. To initiate a formulary exception request directly, providers may also call 855-240-0536.

How to get a non-formulary drug approved?

The process for requesting or filing a formulary exception can vary by insurance company, but in most cases involves providing medical justification, including your health history, the drug's effectiveness, and reasons why the covered alternatives on the formulary may not work for you.

What makes Zepbound medically necessary?

Zepbound may be prescribed if you are living with obesity alone, obesity and obstructive sleep apnea, or with overweight and a weight-related medical condition, and you have not been successful in losing weight or maintaining weight loss with lifestyle changes alone.

For pdfFiller’s FAQs

What is FORMULARY EXCEPTION PHYSICIAN FAX FORM?

The FORMULARY EXCEPTION PHYSICIAN FAX FORM is a document used by healthcare providers to request an exception to the standard formulary list for a patient, allowing coverage for a medication that is not typically covered.

Who is required to file FORMULARY EXCEPTION PHYSICIAN FAX FORM?

Healthcare providers or physicians who are prescribing a medication not included in the patient’s insurance formulary are required to file the FORMULARY EXCEPTION PHYSICIAN FAX FORM.

How to fill out FORMULARY EXCEPTION PHYSICIAN FAX FORM?

To fill out the FORMULARY EXCEPTION PHYSICIAN FAX FORM, the physician must provide patient information, details of the medication requested, clinical rationale for the exception, and any relevant supporting documentation.

What is the purpose of FORMULARY EXCEPTION PHYSICIAN FAX FORM?

The purpose of the FORMULARY EXCEPTION PHYSICIAN FAX FORM is to formally request authorization for a medication that is not covered in the standard formulary, ensuring patients receive necessary treatments.

What information must be reported on FORMULARY EXCEPTION PHYSICIAN FAX FORM?

The information that must be reported includes patient demographic details, insurance information, specific medication requested, dosage, prescribing physician details, and the clinical justification for the exception.