Get Minnesota Uniform Formulary Exception Form - Preferredone

This guide provides comprehensive instructions for users on how to complete the Minnesota Uniform Formulary Exception Form - PreferredOne online. By following these steps, healthcare providers can efficiently submit requests for formulary exceptions, ensuring clarity and compliance with regulations.

Follow the steps to fill out the Minnesota Uniform Formulary Exception Form online.

1. Select the ‘Get Form’ button to access and open the Minnesota Uniform Formulary Exception Form for online completion.
2. Begin by completing Section A, which includes information about the group purchaser. Enter the group purchaser name, contact name, address, phone number, and secure fax number if available.
3. In Section B, provide the patient information including their name, date of birth, address, health plan or pharmacy plan, and the corresponding health plan ID number or pharmacy plan ID number.
4. Move to Section C to fill out the prescriber information. Enter the prescriber's name, NPI, specialty, point of contact name, phone number, and the address of the facility or clinic.
5. In Section D, specify the medication information by listing the drug being requested, its strength, dosing schedule, and expected duration of therapy.
6. Answer whether the patient is currently being treated with the requested drug in Section E, providing additional detail if applicable. Indicate the start date if treatment is ongoing.
7. Continue in Section F by providing a rationale for the formulary exception request. Detail any previous therapies tried or failed and include comments regarding the rationale for the request.
8. After completing all the necessary sections, review the entire form to ensure that all required fields are filled out accurately and clearly to avoid return due to incomplete information.
9. Once the form is completed and verified, users can save the changes made, download, print, or share the form as needed.

Complete your Minnesota Uniform Formulary Exception Form online today to ensure timely submissions and approvals.