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VIRGINIA MEDICAID REQUEST FOR SERVICE AUTHORIZATION ORAL PRODUCTS COMMONWEALTH of VIRGINIA Department of Medical Assistance Services Requests for service authorization (SA) must include patient name,

How to fill out non-formulary drug

How to fill out a non-formulary drug:

1. Consult your healthcare provider: Before filling out a non-formulary drug, it is essential to consult your healthcare provider. They can provide guidance on whether the medication is necessary for your condition and explain why it is non-formulary. They may also suggest alternative medications that are included in your insurance's formulary.
2. Check with your insurance provider: Contact your insurance provider to understand their policies regarding non-formulary drugs. They can explain the coverage options available and any additional steps you might need to take. This is crucial as non-formulary drugs may have limited coverage or require prior authorization.
3. Submit a prior authorization request: If your healthcare provider determines that the non-formulary drug is necessary for your treatment, they may need to submit a prior authorization request to your insurance company. This request typically includes relevant medical documentation supporting the need for the specific medication.
4. Follow up with your healthcare provider and insurance provider: Once the prior authorization request has been submitted, it is important to follow up regularly with both your healthcare provider and insurance provider to check on the progress. You may need to provide additional information or address any concerns raised during the process.
5. Explore alternative options: While awaiting approval or if the non-formulary drug is denied coverage, discuss alternative treatment options with your healthcare provider. They can work with you to find alternative medications that are included in your insurance's formulary. These alternatives may be just as effective for your condition.

Who needs non-formulary drugs?

1. Patients with specific medical conditions: Non-formulary drugs are often prescribed when a patient's medical condition requires a medication that is not included in the insurance company's approved list. This could be due to the drug's cost, limited availability, or other factors determined by the insurance provider.
2. Individuals who have tried formulary alternatives without success: Sometimes, patients may require non-formulary drugs if they have already tried medications available in the insurance's formulary, but they were not effective or caused adverse side effects. In such cases, healthcare providers may consider non-formulary drugs as a potential solution.
3. Patients with insurance plans that allow non-formulary prescriptions: Some insurance plans may offer coverage for non-formulary drugs, but with certain conditions or limitations. In these cases, patients who meet the insurance plan's criteria can access non-formulary drugs as prescribed by their healthcare provider.

It is important to note that the availability and coverage of non-formulary drugs may vary depending on your insurance plan and the specific drug you require. Consulting your healthcare provider and insurance provider will help you navigate the process and determine the best course of action for your specific situation.

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