Get the free Non-Formulary Exception Request - Rx Preferred

Formulary Exception Request ***ONLY COMPLETED REQUESTS WILL BE REVIEWED*** Drug Requested (one drug per form only) Date: Quantity (qty. edit only) Patient ID#: DOB: Patient Name: Provider NPI: Prescribing

How to fill out non-formulary exception request

How to fill out a non-formulary exception request:

1. Start by obtaining a copy of the non-formulary exception request form from your healthcare provider, insurance company, or pharmacy.
2. Carefully read through the instructions provided on the form. Ensure that you understand the purpose of the request and the specific criteria for approval.
3. Begin filling out the personal information section, which usually includes your name, date of birth, insurance details, and contact information. Double-check for accuracy before proceeding.
4. Next, describe the medication for which you are seeking an exception. Include the name, dosage, and any additional relevant information, such as the reason why the medication is necessary for your health condition.
5. Provide details about any previous treatments you have tried for your condition and explain why they were not effective or caused adverse effects.
6. Attach any supporting documentation that may strengthen your case, such as medical records, test results, or a healthcare provider's letter of support. Make sure to include copies rather than original documents.
7. If applicable, outline any financial hardships or accessibility issues that may arise if the non-formulary medication is not approved.
8. Review your completed non-formulary exception request form for accuracy, legibility, and completeness. Make any necessary corrections or additions before submitting it.

Who needs a non-formulary exception request?

1. Individuals who have been prescribed a medication that is not on their insurance company's formulary list may need to submit a non-formulary exception request.
2. Patients who have tried alternative treatments but have not achieved the desired result or have experienced adverse effects may require a non-formulary exception request.
3. Individuals facing financial hardships or accessibility issues related to obtaining an approved medication may also benefit from submitting a non-formulary exception request.

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What is non-formulary exception request?

Non-formulary exception request is a request made to obtain coverage for a medication that is not on the formulary list.

Who is required to file non-formulary exception request?

Any individual whose medication is not on the formulary list and wishes to seek coverage for it.

How to fill out non-formulary exception request?

To fill out a non-formulary exception request, one must provide details about the medication, reason for the request, and any relevant medical documentation.

What is the purpose of non-formulary exception request?

The purpose of a non-formulary exception request is to request coverage for a medication that is not on the formulary list.

What information must be reported on non-formulary exception request?

Information such as medication details, reason for the request, medical documentation, and prescribing physician must be reported on a non-formulary exception request.