Get the free Non-Formulary Drug Request Form - swhp

PRIOR AUTHORIZATION REQUEST FORM EOC ID: SW Exchange Non-Formulary Drug Request Phone: 800-728-7947 Fax back to: 866-880-4532 Scott & White Prescription Services manages the pharmacy drug benefit

How to fill out non-formulary drug request form

How to fill out a non-formulary drug request form:

1. Obtain the non-formulary drug request form from your healthcare provider or insurance company.
2. Start by filling out your personal information on the form, including your name, date of birth, address, and contact information.
3. Provide details about the medication you are requesting, such as the brand name, generic name, dosage, and strength.
4. Explain the reason why you believe this non-formulary medication is necessary for your treatment, providing any supporting documentation or medical records if required.
5. Indicate any previous use or experience with the medication, including any adverse reactions or side effects.
6. If applicable, include information about alternative medications you have tried and why they were not effective or suitable for your condition.
7. Include any additional information or notes that you believe will support your request for the non-formulary drug.
8. Review the completed form for accuracy and completeness before submitting it to your healthcare provider or insurance company.

Who needs a non-formulary drug request form:

1. Patients who have been prescribed a medication that is not covered by their insurance plan's formulary.
2. Individuals who need access to a specific medication that is not readily available or commonly prescribed.
3. Patients who have tried alternative medications listed on the formulary but have not achieved the desired therapeutic outcome.
4. Individuals who have a medical condition that requires a specialized or unique medication that is not typically covered by insurance.

For pdfFiller’s FAQs

What is non-formulary drug request form?

The non-formulary drug request form is a document used to request coverage for medications that are not on the insurance plan's approved list of formulary drugs.

Who is required to file non-formulary drug request form?

Any individual whose prescribed medication is not on the formulary list must file a non-formulary drug request form.

How to fill out non-formulary drug request form?

To fill out a non-formulary drug request form, one must provide their personal information, details of the prescribed medication, reason for non-formulary request, and any supporting documentation.

What is the purpose of non-formulary drug request form?

The purpose of the non-formulary drug request form is to request coverage for medications not typically covered under the insurance plan's formulary list.

What information must be reported on non-formulary drug request form?

Information such as personal details, prescribed medication details, reason for non-formulary request, and any supporting documentation must be reported on the non-formulary drug request form.

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