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OUT OF PLAN Prior Authorization ELITE | COMMERCIAL/HMO Attn: OutofPlan Coordinator Toll Free at (800) 8912520 Fax: 5676610847 Date of Request: ___ ___ Member Name: ___ DOB: ___ Paramount ID#: ___
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How to fill out request for a non-formulary
How to fill out request for a non-formulary
01
Gather all necessary information regarding the non-formulary item such as name, dosage, strength, and reason for needing the item.
02
Contact the insurance provider to verify coverage and obtain any required prior authorization forms.
03
Write a detailed letter explaining the medical necessity of the non-formulary item and why it is required for the patient's treatment.
04
Include any supporting documents such as medical records, test results, or clinical guidelines to strengthen your case.
05
Submit the request, letter, and supporting documents to the insurance provider either through online portal, fax, or mail.
06
Follow up with the insurance provider to ensure timely processing and approval of the request.
Who needs request for a non-formulary?
01
Patients who require medication or treatment that is not covered by their insurance provider's formulary.
02
Healthcare providers who believe a non-formulary item is medically necessary for their patient's treatment.
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What is request for a non-formulary?
A request for a non-formulary is a formal submission to request coverage for a medication not included on the formulary list.
Who is required to file request for a non-formulary?
Patients or healthcare providers are 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 needs to provide essential information about the patient, medication, diagnosis, and reasoning for the request.
What is the purpose of request for a non-formulary?
The purpose of a request for a non-formulary is to obtain approval for coverage of a specific medication that is not on the formulary list.
What information must be reported on request for a non-formulary?
Information such as patient's name, medication name, diagnosis, healthcare provider's information, and justification for the non-formulary request must be reported.
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