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FORM# FRX002 Expedited Formulary Exception Request Form Member Information Provider Information Patient Name Provider Name Cardholder ID DEA Number Date of Birth Address City, State and Zip City,

How to fill out expedited formulary exception request

How to fill out expedited formulary exception request

1. Read the instructions provided on the expedited formulary exception request form.
2. Collect all necessary documents and information required for the request, such as medical records, prescription details, and supporting documents.
3. Fill out the expedited formulary exception request form accurately and completely. Provide detailed information about the medication, dosage, and reason for the exception request.
4. Ensure all required fields are filled in and any necessary signatures are obtained.
5. Attach all supporting documents to the request form, making sure they are organized and easily readable.
6. Submit the completed expedited formulary exception request form along with all supporting documents to the appropriate authority or organization, according to their instructions.
7. Keep a copy of the completed request form and supporting documents for your records.
8. Follow up with the authority or organization to check the status of your request and provide any additional information if requested.
9. Wait for a response from the authority or organization regarding the approval or denial of your expedited formulary exception request.
10. If approved, follow any further instructions provided, such as obtaining the medication and maintaining necessary documentation.
11. If denied, review the reasons provided for the denial and consider appealing the decision if necessary.

Who needs expedited formulary exception request?

1. Individuals who require a medication that is not included in their insurance plan's formulary.
2. Patients who need access to a medication that is considered non-preferred or requires prior authorization.
3. People who have tried alternative medications from the formulary without success or have experienced adverse side effects.
4. Individuals for whom a formulary medication does not adequately address their medical condition or treatment needs.
5. Patients who require a specific brand-name medication when only generic alternatives are listed in the formulary.

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What is expedited formulary exception request?

Expedited formulary exception request is a process in which a patient or their physician can request coverage for a prescription drug that is not on the health plan's formulary, but is deemed medically necessary.

Who is required to file expedited formulary exception request?

Patients or their physicians are required to file expedited formulary exception requests if they need coverage for a prescription drug that is not on the health plan's formulary.

How to fill out expedited formulary exception request?

To fill out an expedited formulary exception request, the patient or physician must provide detailed information about the drug, the medical necessity, and any alternative treatments that have been tried.

What is the purpose of expedited formulary exception request?

The purpose of an expedited formulary exception request is to ensure that patients have access to medically necessary drugs that may not be on the health plan's formulary.

What information must be reported on expedited formulary exception request?

The expedited formulary exception request must include information about the patient, the prescribing physician, the drug being requested, the medical necessity, and any supporting documentation.