Get Gateway Health Plan Drug Exception Form

Filling out the GATEWAY HEALTH PLAN DRUG EXCEPTION FORM is an essential step for individuals seeking coverage for nonformulary drugs or quantity limit exceptions. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by entering the Member ID in the designated field. This unique identifier is essential for processing your request.
3. Fill in the Member Name and Date of Birth to ensure accurate identification of the individual requesting the drug exception.
4. Next, input the Pharmacy Name and Pharmacy Phone number to provide the necessary contact information for the dispensing pharmacy.
5. In the Drug Name field, list the specific nonformulary drug for which you are requesting coverage.
6. Specify the Dosage/Frequency of the prescribed drug to give the reviewer clear information on how the drug is to be taken.
7. Provide the Diagnosis for which the drug is prescribed, ensuring you include relevant details to support the request.
8. Document the formulary alternatives that have previously been used by the patient, detailing the Drug Name, Strength, and Dates Used for each alternative.
9. In the space provided, include a rationale for the requested drug, outlining why formulary alternatives were ineffective or led to adverse reactions.
10. If additional clinical information is needed, include it in the section provided or attach extra pages as necessary.
11. Last, ensure the Physician Name is clearly printed along with their Phone number. Obtain the Physician's signature and date it to authenticate the form.
12. Save your changes and choose to download, print, or share the completed form as required. Finally, fax the form to (888) 245-2049.

Complete your GATEWAY HEALTH PLAN DRUG EXCEPTION FORM online today for efficient processing.