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NC Medicaid and NC Health Choice Pharmacy Prior Approval Request monoclonal Antibodies: Holier NASAL POLYPS Beneficiary Information 1. Beneficiary Last Name: ___ 2. First Name: ___ 3. Beneficiary
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How to fill out formulary exception request page
How to fill out formulary exception request page
01
Download the formulary exception request form from the website.
02
Fill out all required information, such as patient's name, prescription details, and reason for the exception request.
03
Attach any supporting documents, such as medical records or doctor's notes, if necessary.
04
Submit the completed form and any supporting documents to the designated address or fax number.
Who needs formulary exception request page?
01
Patients who have a prescription that is not covered by their insurance's formulary list.
02
Healthcare providers who are requesting an exception to the formulary list on behalf of their patients.
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What is formulary exception request page?
Formulary exception request page is a form used to request coverage for a drug that is not included in the health plan's formulary.
Who is required to file formulary exception request page?
Patients or their healthcare providers are required to file formulary exception request page.
How to fill out formulary exception request page?
To fill out the formulary exception request page, the patient or healthcare provider must provide information about the patient, the drug being requested, and the reason for the request.
What is the purpose of formulary exception request page?
The purpose of formulary exception request page is to request coverage for a drug that is not on the health plan's formulary.
What information must be reported on formulary exception request page?
The formulary exception request page must include information about the patient, the drug being requested, and the reason for the request.
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