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Prescriber Criteria Formally Health Medicare 2019 PA Fax C2915A FHC v1 120118.docx () Coverage Determination This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

How to fill out formulary exceptionprior authorization request

How to fill out formulary exceptionprior authorization request

1. Step 1: Obtain the formulary exception prior authorization request form from your insurance provider.
2. Step 2: Fill out the patient information section, including your name, date of birth, and insurance information.
3. Step 3: Provide details about the requested medication, including the name, dosage, and frequency of use.
4. Step 4: Explain the reason for requesting a formulary exception, such as an allergy or adverse side effects to the insurance-preferred medication.
5. Step 5: Attach any supporting documentation or medical records that can help justify the need for the exception.
6. Step 6: Submit the completed form and any supporting documents to your insurance provider through the designated channels, such as online portal, fax, or mail.
7. Step 7: Keep a copy of the submitted form and documents for your records.
8. Step 8: Follow up with your insurance provider to ensure that your request is being processed and to inquire about the status of the exception prior authorization.

Who needs formulary exceptionprior authorization request?

1. Individuals who require medications that are not covered by their insurance's formulary list.
2. Patients who have tried the insurance-preferred medications but experienced adverse reactions or inadequate therapeutic response.
3. People with specific medical conditions or allergies that require alternative medications.
4. Individuals whose healthcare providers believe that a formulary exception is necessary for their treatment.

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