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COVERAGE DETERMINATION REQUEST FORM EOC ID: Elixir DAY Penalty Form Phone: 8003614542Fax back to: 8664143453Elixir manages the pharmacy drug benefit for your patient. Certain requests for coverage

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What is elixir non formulary exception?

Elixir non formulary exception is a request for coverage of a medication that is not included in the formulary list of approved drugs by the insurance provider.

Who is required to file elixir non formulary exception?

Patients or healthcare providers are required to file elixir non formulary exception.

How to fill out elixir non formulary exception?

To fill out elixir non formulary exception, you need to provide details of the medication, medical necessity, and supporting documentation.

What is the purpose of elixir non formulary exception?

The purpose of elixir non formulary exception is to request coverage for medications that are not included in the formulary list due to medical necessity.

What information must be reported on elixir non formulary exception?

Information such as patient demographics, medication details, medical necessity, and supporting documentation must be reported on elixir non formulary exception.

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