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Pharmacy Prior Authorization Title 19/21 SMI Formulary and Prior Authorization Guidelines Scroll down to see PA Criteria by drug class, or Ctrl+F to search document by drug nameGeneral GuidelinesAuthorization

How to fill out non-formulary and prior authorization

How to fill out non-formulary and prior authorization

1. To fill out a non-formulary request, follow these steps:
2. Obtain the non-formulary request form from the insurance provider or download it from their website.
3. Fill in the patient's personal information, including name, date of birth, and insurance ID number.
4. Provide details about the prescribed medication, such as the brand name, dosage, and strength.
5. Include a brief explanation for why the non-formulary medication is necessary.
6. Attach any supporting documents, such as medical records or a doctor's note.
7. Submit the completed form to the insurance provider either via mail, fax, or through their online portal.
9. To fill out a prior authorization request, follow these steps:
10. Obtain the prior authorization form from the insurance provider or download it from their website.
11. Fill in the patient's personal information, including name, date of birth, and insurance ID number.
12. Provide details about the prescribed medication, including the brand name, dosage, and strength.
13. Include a detailed explanation for why the medication is necessary and why alternative treatments are not suitable.
14. Attach any supporting documentation, such as medical records, test results, or a doctor's note.
15. Submit the completed form to the insurance provider either via mail, fax, or through their online portal.

Who needs non-formulary and prior authorization?

1. Patients who require non-formulary medications or medications that are not on their insurance provider's list need to fill out a non-formulary request.
2. Patients who need medications that require prior authorization from their insurance provider need to fill out a prior authorization form.

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What is non-formulary and prior authorization?

Non-formulary refers to medications that are not included on the list of approved drugs for coverage by a particular health plan. Prior authorization is a requirement by some insurance companies that healthcare providers must obtain approval before prescribing certain medications or treatments.

Who is required to file non-formulary and prior authorization?

Healthcare providers, such as doctors and pharmacists, are usually the ones required to file non-formulary and prior authorization requests with insurance companies.

How to fill out non-formulary and prior authorization?

To fill out a non-formulary and prior authorization request, healthcare providers typically need to provide information about the patient, the medication being prescribed, and the reason why it is necessary.

What is the purpose of non-formulary and prior authorization?

The purpose of non-formulary and prior authorization is to ensure that patients receive appropriate and cost-effective care, by requiring healthcare providers to justify the medical necessity of certain medications before they are prescribed.

What information must be reported on non-formulary and prior authorization?

Information that must be reported on non-formulary and prior authorization requests may include patient demographics, medical history, diagnosis, proposed treatment plan, and documentation supporting the necessity of the requested medication.