Get the free Preauthorization/Non-Formulary Medication Request Form

The Blue Cross and Blue Shield Federal Employee Program (FEP) and the American Medical Association (AMA) have come together in a collaborative effort to provide physicians with resources designed

How to fill out preauthorizationnon-formulary medication request form

How to fill out preauthorizationnon-formulary medication request form

1. To fill out the preauthorization non-formulary medication request form, follow these steps:
2. Start by entering your personal information, such as your name, date of birth, and contact details, in the designated fields.
3. Provide the details of your healthcare provider, including their name, contact information, and any relevant identification numbers.
4. Specify the non-formulary medication you are requesting preauthorization for. Include the brand or generic name, strength, dosage form, and the reason for prescribing it.
5. Attach any supporting documents that may be required, such as medical records, test results, or comprehensive treatment plans.
6. Review the completed form to ensure all information is accurate and complete.
7. Sign and date the form to certify the information provided is true and accurate.
8. Submit the form to the appropriate department or insurance company as instructed, either by mail, fax, or online portal.
9. Keep a copy of the completed form and any supporting documents for your records.

Who needs preauthorizationnon-formulary medication request form?

1. The preauthorization non-formulary medication request form is typically required by individuals who need to request coverage for medications that are not included in their insurance plan's formulary. Formulary medications are the drugs covered by the insurance company's list of approved medications, while non-formulary medications are those that may require additional approval or review before they can be covered. Individuals who have been prescribed a non-formulary medication by their healthcare provider and wish to have it covered by their insurance plan will need to fill out this form to request preauthorization.

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What is preauthorizationnon-formulary medication request form?

A preauthorizationnon-formulary medication request form is a document used to request approval for medications that are not on the approved formulary list.

Who is required to file preauthorizationnon-formulary medication request form?

Patients or healthcare providers may be required to file the preauthorizationnon-formulary medication request form.

How to fill out preauthorizationnon-formulary medication request form?

The form typically requires information such as patient's personal details, medical history, prescribing healthcare provider, reason for non-formulary medication request, etc.

What is the purpose of preauthorizationnon-formulary medication request form?

The purpose of the form is to obtain approval for medications that are not typically covered by insurance or on the approved formulary list.

What information must be reported on preauthorizationnon-formulary medication request form?

Information such as patient's personal details, medical history, prescribing healthcare provider, reason for non-formulary medication request, etc. must be reported on the form.