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Print Form Policy #: 434 Clear form fields Posted: 1/1/2012 Page: 1 of 1 Request for Outpatient Retail Pharmacy Prior Authorization Fax to: Clinical Pharmacy Program (800) 583-6289 or Web: https://provider.express-path.com.

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If a medication is “non-formulary,” it means it is not included on the insurance company's “formulary” or list of covered medications. A medication may not be on the formulary because an alternative is proven to be just as effective and safe but less costly.

A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary, or to request to have a utilization management requirement waived (e.g., step therapy, prior authorization, quantity limit) for a formulary drug.

Often, non-formulary drug request forms are used to request a nonformulary drug. The form should contain the patient basic information, the rationale of use, the volume of drugs needed.

Formulary Exceptions are necessary for certain drugs that are eligible for coverage under your health plan's drug benefit. If the request is not approved by the health plan you may still purchase the medication at your own expense.

The most commonly prescribed classes of non-formulary drugs were immunobiologicals (vaccines), antiemetics, vitamins, psychotropic drugs, beta blockers, and systemic antimycotics and antibacterials.

If you need a drug that is not on your health plan's formulary, you must get your plan's approval or pay for the drug yourself. Your doctor should ask the plan for approval. In certain cases, a health plan may be required to cover a drug that is not on your plan's formulary.

If you need a drug that is not on your health plan's formulary, you must get your plan's approval or pay for the drug yourself. Your doctor should ask the plan for approval. In certain cases, a health plan may be required to cover a drug that is not on your plan's formulary.

A formulary is a list of generic and brand name prescription drugs covered by your health plan. Non-formulary drugs typically only include brand-name medications and come with high out-of-pocket expenses. Your health plan may only help you pay for the drugs listed on its formulary.

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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232