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Document adverse effects requiring discontinuation and/or reason for perceived ineffectiveness. Attach additional pages if necessary. If all formulary agents would not be effective please specify prior treatment failures If patient preference for nonformulary drug please provide your clinical rationale If no available formulary alternatives have been previously tried please check this box. Please address why all formulary alternatives on any tier of the formulary for treatment of the same...

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3. Step 3: Locate the fields on the form where you need to enter your information.
4. Step 4: Using a pen or electronic typing tool, enter the required information in each field accurately.
5. Step 5: Double-check the form for any errors or missing information.
6. Step 6: If applicable, attach any supporting documents or additional information to the form as instructed.
7. Step 7: Once you have filled out all the necessary information, review the form again to ensure its completeness.
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9. Step 9: Print the completed form if required.
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11. Step 11: If faxing via a physical fax machine, ensure the form is positioned correctly and dial the recipient's fax number.
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