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REQUEST FOR A FORMULARY PRIOR AUTHORIZED DRUG EXCEPTION OR STEP THERAPY Member Name: DOB: Member ID number: Date: Diagnosis: Is this an appeal to a previously denied request? YES or NO (A separate
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How to fill out request for a non-formulary
How to fill out request for a non-formulary:
01
Obtain the necessary request form: Contact your healthcare provider or insurance company to obtain the specific form required for submitting a request for a non-formulary medication. This form may vary depending on your healthcare provider or insurance company.
02
Gather relevant information: Before filling out the request form, gather all the necessary information that may be required to complete the form. This may include your personal details, insurance information, healthcare provider's contact information, and the medication details such as the name, dosage, and purpose.
03
Provide detailed justification: In the request form, include a detailed justification explaining why the non-formulary medication is medically necessary for your condition. Provide supporting evidence such as medical records, lab results, or authoritative guidelines that demonstrate the effectiveness or superiority of the requested medication over the formulary alternatives.
04
Follow the instructions: Carefully read the instructions provided on the request form and ensure that you comply with all the requirements. This may involve signing and dating the form, providing additional documentation, or obtaining your healthcare provider's signature or prescription.
05
Submit the request: Once you have completed the request form and gathered all the necessary documentation, submit the request to your healthcare provider or insurance company as directed. It is recommended to make copies of all the submitted documents for your records.
06
Keep track of the process: After submitting the request, maintain communication with your healthcare provider and insurance company to track the progress of your request. This may involve following up with any additional information they may require or inquiring about the status of your application.
Who needs request for a non-formulary?
01
Patients with specific medical needs: Individuals who require a medication that is not included in their insurance company's formulary may need to submit a request for a non-formulary medication. This could be because the formulary alternatives are not suitable or effective for their specific medical condition.
02
Healthcare providers: Physicians, specialists, or other healthcare professionals may need to fill out a request for a non-formulary on behalf of their patients. They would need to provide the necessary medical justification and supporting documentation to demonstrate the medical necessity of the requested medication.
03
Insurance companies: Insurance companies require a request for a non-formulary to evaluate the medical necessity of the medication and determine whether to provide coverage for it. Their involvement ensures appropriate use of healthcare resources and facilitates the review process for non-formulary medications.
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What is request for a non-formulary?
A request for a non-formulary is a formal submission made to request coverage for a medication that is not on the formulary list.
Who is required to file request for a non-formulary?
Any individual whose prescribed medication is not on the formulary list is required to file a request for a non-formulary.
How to fill out request for a non-formulary?
To fill out a request for a non-formulary, one must provide necessary information about the medication, medical condition, and reasons for requesting coverage.
What is the purpose of request for a non-formulary?
The purpose of request for a non-formulary is to seek approval for coverage of a medication that is not included in the formulary list.
What information must be reported on request for a non-formulary?
The request for a non-formulary must include information such as the medication name, dosage, duration of treatment, prescriber information, and medical justification.
How can I send request for a non-formulary to be eSigned by others?
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