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Use for Blue Medicare Rx Enhanced Plan FORMULARY DRUG REQUEST FORM (Incomplete form may delay processing) Patient Information Prescriber Information Patient Name: Physician Name: NPI #: Patient ID

How to fill out non-formulary drug request form

How to fill out a non-formulary drug request form:

1. Start by filling out your personal information section. This includes your name, address, phone number, and any other relevant contact details.
2. Next, provide your insurance information. This may include your policy number, group number, and the name of your insurance provider.
3. In the "Prescription Details" section, list the name of the non-formulary drug you are requesting. Provide as much information as possible, such as the dosage and any specific instructions from your healthcare provider.
4. Include a brief description of the medical condition for which the non-formulary drug is needed. Explain why the drug is necessary and any alternative treatments that have been tried or considered.
5. If applicable, attach any supporting documentation, such as medical records or a letter from your healthcare provider explaining the need for the non-formulary drug.
6. Review the form to ensure that all sections are completed accurately and comprehensively.

Who needs a non-formulary drug request form?

1. Patients who have been prescribed a medication that is not covered by their insurance provider's formulary list may need to fill out a non-formulary drug request form. This form allows the patient to request coverage for the non-formulary drug.
2. Individuals who have tried alternative medications listed on the formulary list but have not experienced the desired results may also need to submit a non-formulary drug request form.
3. Patients who have a medical condition for which an alternative formulary drug is not recommended or available may require a non-formulary drug request form to access the necessary medication.

Overall, individuals who require a non-formulary drug that is not covered by their insurance provider's formulary list would benefit from completing a non-formulary drug request form to seek coverage for the medication needed to address their medical condition.

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What is non-formulary drug request form?

Non-formulary drug request form is a form used to request medications that are not included on the organization's approved drug list or formulary.

Who is required to file non-formulary drug request form?

Healthcare providers, pharmacists, or patients may be required to file the non-formulary drug request form.

How to fill out non-formulary drug request form?

The non-formulary drug request form can typically be filled out by providing information about the patient, the medication being requested, the reason for the request, and any supporting documentation.

What is the purpose of non-formulary drug request form?

The purpose of the non-formulary drug request form is to provide a process for requesting non-formulary medications when medically necessary alternatives are not suitable.

What information must be reported on non-formulary drug request form?

The non-formulary drug request form may require information such as the patient's demographics, medical history, the requested medication, dosage, frequency, and rationale for the request.