Get the free Non-Preferred Medication Request

This form is used to request prior authorization for non-preferred medications, requiring information about the patient, physician, medication details, and approval criteria.

How to fill out non-preferred medication request

How to fill out Non-Preferred Medication Request

1. Start by obtaining the Non-Preferred Medication Request form from your healthcare provider or insurance company.
2. Fill in the patient's personal information at the top of the form, including name, date of birth, and insurance policy number.
3. Provide the medication details, including the name of the non-preferred medication, dosage, and frequency.
4. Fill out the reasons for requesting the non-preferred medication, including any relevant medical history or treatment failures with preferred medications.
5. Attach any necessary supporting documents, such as medical records or previous treatment notes.
6. Sign and date the form to verify the accuracy of the information provided.
7. Submit the completed form to your healthcare provider or insurance company as instructed.

Who needs Non-Preferred Medication Request?

1. Patients who require a specific non-preferred medication that is not covered by their health insurance plan.
2. Individuals who have experienced ineffective treatment with preferred medications.
3. Patients with specific medical conditions that necessitate the use of a non-preferred medication.

People Also Ask about

What does non-preferred prescription mean?

These are brand-name drugs that are not included on the plan's formulary (list of preferred prescription drugs). Non-preferred brand-name drugs have higher coinsurance than preferred brand-name drugs. You pay more if you use non-preferred drugs than if you opt for generics and preferred brand-name drugs.

What is a non-preferred prescription?

What are preferred and non-preferred drugs? Often two brand-name drugs are useful for the same problem. Your insurance company may be able to get one less expensively than the other. That drug becomes a preferred drug, and the other becomes non-preferred. That's usually why you pay more for non-preferred drugs.

What is a non-formulary request?

A doctor may prescribe a non-formulary drug when covered therapies haven't been effective for you. If you and your doctor have decided that a non-formulary drug is right for you, your doctor can request approval. Getting approval helps you lower your out-of-pocket costs.

What is the difference between preferred and non-preferred pharmacies?

If your plan has “preferred in-network pharmacies,” they may save you money on your out-of-pocket drug costs (like a copayment or coinsurance) because they have agreed to charge less than other pharmacies in your plan's network.

What does it mean when a drug becomes non-preferred?

Non-preferred Brand-Name Drugs These drugs have the highest copayment, and there is a special coinsurance amount of 50 percent for fertility medications. Generally these are higher-cost medications that have recently come on the market. In most cases, an alternative preferred medication is available.

What does "preferred" vs "non-preferred" mean?

What is the difference between a preferred drug and a non-preferred drug? Often two brand name drugs help treat the same problem, but one has been shown to be more cost- or medically effective than the other. That more effective drug becomes a preferred drug and the other becomes a non-preferred drug.

What is the difference between prescription and nonprescription?

Over-the-counter (OTC) medications allow you to self-treat conditions such as allergies, headaches, joint pain, and more. Prescription medications require an order from a healthcare professional. You can buy OTC treatments at supermarkets, drugstores, and other retail locations.

What is a non-prescribed medication called?

(NON-preh-SKRIP-shun) Refers to a medicine that can be bought without a prescription (doctor's order). Examples include analgesics (pain relievers), such as aspirin and acetaminophen. Also called OTC and over-the-counter.

For pdfFiller’s FAQs

What is Non-Preferred Medication Request?

A Non-Preferred Medication Request is a formal application submitted to a health insurance provider to seek approval for a medication that is not included on the insurer's preferred drug list.

Who is required to file Non-Preferred Medication Request?

Physicians or healthcare providers are required to file a Non-Preferred Medication Request on behalf of their patients when they prescribe a medication that is not covered under the patient's insurance plan.

How to fill out Non-Preferred Medication Request?

To fill out a Non-Preferred Medication Request, a healthcare provider must provide patient information, prescription details, reasons for the request, and any supporting documentation or clinical rationale for the non-preferred medication.

What is the purpose of Non-Preferred Medication Request?

The purpose of a Non-Preferred Medication Request is to obtain authorization from insurance providers for medications that are necessary for a patient's treatment but are not part of the standard coverage.

What information must be reported on Non-Preferred Medication Request?

The information that must be reported includes the patient's personal details, details of the prescribing physician, medication name and dosage, diagnosis, previous treatments tried, and justification for the use of the non-preferred medication.