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FORMULARY REQUEST PHYSICIAN CERTIFICATION FORMULARY REQUEST FORM Please fill out the following information and return to us as indicated below: A. Member Information: Patient Name: Carrier ID: HP

How to fill out non-formulary request physician certification

How to fill out non-formulary request physician certification:

1. Begin by obtaining the non-formulary request physician certification form from the relevant healthcare provider or insurance company.
2. Carefully read through the instructions on the form to ensure that you understand all the requirements and necessary information.
3. Fill in your personal details such as your name, contact information, and any identification numbers that may be required.
4. Specify the patient's information for whom the non-formulary request is being made. This may include their name, date of birth, and any relevant medical history or conditions.
5. Provide the details of the medication for which the non-formulary request is being made. Include the medication name, strength, dosage, and any specific instructions or reasons for requesting it.
6. If applicable, include any supporting documentation or medical records that may be necessary to substantiate the need for the non-formulary medication. This can include medical reports, test results, or physician notes.
7. Ensure that you complete all additional sections or questions on the form, such as the signature and date fields.
8. Double-check all the information provided to ensure it is accurate and complete.
9. Submit the filled-out non-formulary request physician certification form to the designated healthcare provider or insurance company as instructed.

Who needs non-formulary request physician certification?

1. Patients who require a medication that is not included in the formulary of their healthcare provider or insurance plan may need a non-formulary request physician certification.
2. Non-formulary medications are typically those that are not usually covered by insurance or that have a higher cost than alternative medications on the formulary.
3. Patients who have tried alternative medications on the formulary but have not had success or experienced adverse side effects may need to request a non-formulary medication.
4. In some cases, patients with specific medical conditions or complex health needs may require medication options that are not included in the formulary, making non-formulary request physician certification necessary.

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What is non-formulary request physician certification?

Non-formulary request physician certification is a form that must be completed by a physician to request coverage for a medication that is not on the health plan's formulary list.

Who is required to file non-formulary request physician certification?

Physicians who wish to prescribe a medication that is not on the health plan's formulary list are required to file a non-formulary request physician certification.

How to fill out non-formulary request physician certification?

To fill out the non-formulary request physician certification, the physician must provide information about the patient, the prescribed medication, and the reason why the medication is necessary.

What is the purpose of non-formulary request physician certification?

The purpose of the non-formulary request physician certification is to request coverage for a medication that is not included in the health plan's formulary list.

What information must be reported on non-formulary request physician certification?

The non-formulary request physician certification must include information about the patient, the prescribed medication, the medical necessity of the medication, and any supporting documentation.