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Elector Patch and Li cart Topical NC Standard
PRIOR REVIEW/CERTIFICATION FATBACK FORM
INCOMPLETE FORMS MAY DELAY PROCESSING
ALL NC PROVIDERS MUST PROVIDE THEIR 5DIGIT Blue Cross NC PROVIDER ID# BELOW
PRESCRIBER
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How to fill out nonformulary exception request or
How to fill out nonformulary exception request or
01
Contact your healthcare provider to discuss the need for a nonformulary medication
02
Gather necessary medical documentation to support the request
03
Complete the nonformulary exception request form provided by your insurance company
04
Submit the form along with the supporting documentation to your insurance company for review
Who needs nonformulary exception request or?
01
Patients who require a medication that is not on their insurance company's formulary
02
Patients whose healthcare provider has recommended a nonformulary medication as the most appropriate treatment option
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What is nonformulary exception request?
A nonformulary exception request is a formal appeal submitted by a patient or healthcare provider to obtain coverage for a medication that is not included in a health plan's formulary.
Who is required to file nonformulary exception request?
The patient, healthcare provider, or pharmacist can file a nonformulary exception request, typically in coordination with the patient's insurance provider.
How to fill out nonformulary exception request?
To fill out a nonformulary exception request, provide patient information, details about the medication requested, justification for the exception, and any supporting documentation from healthcare providers.
What is the purpose of nonformulary exception request?
The purpose of a nonformulary exception request is to seek prior authorization for coverage of a medication that is not listed on the formulary, thereby allowing access to necessary treatments.
What information must be reported on nonformulary exception request?
The information required typically includes patient demographics, medication details, prescribing physician information, justification for the request, and any relevant medical history.
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