Get the free Formulary Exception Approval Form - Land of Lincoln Health

Catamaran Prior Authorization Department Phone: 8006260072 Fax: 8665112202 Prescriber Information Last Name First Name DEA / NPI Specialty Phone Fax Member Information Last Name First Name Member

How to fill out formulary exception approval form

How to fill out formulary exception approval form:

1. Start by carefully reading the instructions provided on the form. Make sure you understand the purpose and requirements of the formulary exception approval process.
2. Provide personal information: Fill in your name, address, date of birth, phone number, and any other required identification details. Be sure to double-check the accuracy of the information provided.
3. Specify the medication: Clearly indicate the name of the medication for which you are seeking an exception. Include the dosage strength and form (e.g., tablets, capsules).
4. Explain the medical necessity: In a separate section, provide a detailed explanation as to why the requested medication is medically necessary for your condition. Include relevant medical history, previous treatments, and any supporting documentation (e.g., doctor's notes, test results) if required.
5. Include any additional information: If there are any other factors that support your request, such as allergies or adverse reactions to alternative medications, make sure to mention them in the appropriate section of the form.
6. Obtain healthcare provider's signature: If required, ensure that your healthcare provider signs the form to confirm their support for your request. This may include your primary care physician, specialist, or prescribing physician.
7. Review and submit: Go through the form again to check for any errors or missing information. Make a copy for your records, and then submit the form as instructed. It is advisable to keep a record of the date and method of submission.
8. Follow up: If there are any further steps or actions required after submitting the form, make sure to follow them promptly. This may include contacting your healthcare provider or insurance company to confirm receipt of the form.

Who needs formulary exception approval form:

1. Patients with health insurance plans that have a formulary, which is a list of medications covered by the plan.
2. Individuals whose prescribed medication is not listed on the formulary and require an exception to have it covered by their insurance.
3. Patients who believe that an alternative medication listed on the formulary may not be effective or may have adverse effects in their specific medical condition.

For pdfFiller’s FAQs

What is formulary exception approval form?

The formulary exception approval form is a document used to request approval for the use of a medication that is not typically covered by a health insurance plan's formulary.

Who is required to file formulary exception approval form?

Patients or healthcare providers are required to file the formulary exception approval form.

How to fill out formulary exception approval form?

To fill out the formulary exception approval form, the individual must provide information about the patient, the medication being requested, and the reason for the exception.

What is the purpose of formulary exception approval form?

The purpose of the formulary exception approval form is to request coverage for a specific medication that is not typically covered by the insurance plan.

What information must be reported on formulary exception approval form?

The formulary exception approval form must include information about the patient, the prescriber, the medication being requested, and the medical reasons for the exception.

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