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  • Futurescripts Non-formulary Exception Request Form

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Provider NPI: Prescribing Physician: ... ONLY COMPLETED REQUESTS WILL BE REVIEWED. 1. PROVIDER SPECIALTY (specify all). 2. DIAGNOSIS FOR .

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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 there is an alternative proven to be just as effective and safe, but is less costly.

The best way to request a drug formulary Exception is with the help of your prescribing doctor or other prescriber. He or she must provide a written statement that explains the medical reasons for requesting an Exception.

Ask your plan how to send your tiering exception request. It is usually helpful to include a letter of support from your prescribing physician. This letter should explain why similar drugs on the plan's formulary at lower tiers are ineffective or harmful for you.

An exception request is a type of coverage determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception.

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 there is an alternative proven to be just as effective and safe, but is less costly.

FutureScripts mail order service is a convenient and cost-effective way for you to order up to a 90-day supply of maintenance or long-term medication for delivery to your home, office or location of your choosing. In addition to the ease of ordering from home, plan participants may also save money.

An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception. A tiering exception should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier.

For tiering exception requests, you or your doctor must show that drugs for treatment of your condition that are on lower tiers are ineffective or dangerous for you.

Formulary prescriptions are medications that are on a preferred drug list. ... Drugs that are usually considered non-formulary are ones that are not as cost effective and that usually have generic equivalents available. 3. How can I find out if my brand name prescription is formulary or non-formulary?

M EX = Medical Exception - This means the member or treating physician or health care professional must obtain a medical exception from Aetna, in order for the medication to be eligible for coverage. Medical Exception criteria apply to non-formulary drugs for members enrolled in or covered by closed benefits plans.

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© Copyright 1997-2025
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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