SilverScript Non-Formulary Exception Form 2012 free printable template

Fax completed form to: 1-855-633-7673 Questions, please call: 1-866-235-5660, 24 hours a day, 7 days a week (TTY users call: 1-866-236-1069) Important Information about Prescription Drug Coverage

How to fill out SilverScript Non-Formulary Exception Form

How to fill out SilverScript Non-Formulary Exception Form

1. Obtain the SilverScript Non-Formulary Exception Form from the official SilverScript website or your pharmacy.
2. Fill out the patient's personal information including name, date of birth, and insurance details.
3. Provide the medication name and dosage that is not on the formulary.
4. Explain the medical necessity for the requested medication, including the reasons why formulary alternatives are not suitable.
5. Include the prescribing physician's information and signature.
6. Submit the completed form to SilverScript via the provided submission method (fax, mail, or electronic submission).
7. Wait for a response from SilverScript regarding the approval or denial of the exception request.

Who needs SilverScript Non-Formulary Exception Form?

1. Patients who require a medication that is not covered under the SilverScript formulary.
2. Healthcare providers who are prescribing medications not listed on SilverScript's formulary.
3. Pharmacists assisting patients with medication needs that may require prior authorization.

Instructions and Help about SilverScript Non-Formulary Exception Form

Let's walk through an example of an EPA request that requires additional information on your part in order to complete the process double-click on the to-do list notification to open the EPA status dialogue remember you can also right-click on the medication name from the face sheet and select open EPA status dialog to get here as well if you would like to cancel this EPA request you will have the option to do so from this dialog by clicking cancel process to address the prior authorization questions click the link for complete PA form located to the right of action required you will then be taken to a summary screen where you will click star in order to begin the process then answer each question and click Next to proceed if you would like to go back to the previous screen click back if you would like to cancel your answer to this question and go back to the previous screen then click release if you would like to save your answers and finish later click save on any of the screens otherwise click Submit to send your answers to the IBM you will then be taken to the process history for this request if you would like to review the information you just submitted click the call-out next to complete PA form to do so when you are done viewing the EPA request click the red X in the upper right corner to close the EPA status dialogue at this point you may also want to delete the to-do list notification regarding the status change for this EPA request which is done by highlighting the message and clicking delete

People Also Ask about

How to request for coverage of a non formulary drug SilverScript?

Please call our Customer Care number at 1-866-235-5660 (TTY: 711), 24 hours a day, 7 days a week.

How do you get a formulary exception?

Most plans require that your doctor submit a formulary exception on your behalf. The doctor will need to send paperwork to your health plan indicating the reason that you can't take the preferred medications and must have one that is not currently on the formulary.

What is non-formulary drug coverage?

A formulary is a list of generic and brand name prescription drugs covered by your health plan. Non-formulary drugs typically only include brand-name medications and come with high out-of-pocket expenses. Your health plan may only help you pay for the drugs listed on its formulary.

What is SilverScript prescription drug plan?

What is SilverScript? SilverScript is a private Medicare Part D insurance company that offers prescription drug coverage to those with Original Medicare. The carrier offers coverage options in all 50 states and Washington D.C. SilverScript offers three different coverage choices to those eligible for Medicare Part D.

Is SilverScript a good prescription plan?

SilverScript plans from Aetna are the best choice for Medicare Part D in 2023. They have the highest ratings and reasonable costs of $39 per month, on average.

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What is SilverScript Non-Formulary Exception Form?

The SilverScript Non-Formulary Exception Form is a document used to request coverage for medications that are not listed on the SilverScript prescription drug formulary.

Who is required to file SilverScript Non-Formulary Exception Form?

Individuals enrolled in a SilverScript prescription drug plan who need a medication that is not covered on the formulary are required to file this form.

How to fill out SilverScript Non-Formulary Exception Form?

To fill out the form, you need to provide patient information, details about the requested medication, the reason for the request, and any relevant medical information supporting the need for the medication.

What is the purpose of SilverScript Non-Formulary Exception Form?

The purpose of the form is to allow beneficiaries to appeal for coverage of medications that are not included in the standard formulary, based on medical necessity.

What information must be reported on SilverScript Non-Formulary Exception Form?

The form must report patient information, the name and dosage of the requested medication, the prescribing physician's information, the reason for the exception, and supporting documentation of medical necessity.