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Get Futurescripts Non-formulary Exception Request Form
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How to fill out the FutureScripts Non-Formulary Exception Request Form online
The FutureScripts Non-Formulary Exception Request Form is designed to help patients request medications that are not typically covered by their insurance plan. This guide will provide a clear, step-by-step approach to filling out the form online, ensuring your request is complete and ready for submission.
Follow the steps to successfully complete the form.
- Click the ‘Get Form’ button to access the FutureScripts Non-Formulary Exception Request Form and open it for editing.
- Begin by entering the drug requested. Clearly state the name of the medication in the designated field.
- Indicate the quantity of the drug requested in the specified box. Ensure that this number reflects the correct amount needed.
- Fill in the date you are submitting the request in the provided field.
- Record the Patient ID number and date of birth (DOB) of the patient. This information is crucial for identification purposes.
- Write the patient's full name in the space allocated for this information.
- Enter the provider's National Provider Identifier (NPI) number in the corresponding field.
- Include the name of the prescribing physician. This should be the doctor who is recommending the medication.
- Provide the office contact person's name, along with their fax number and phone number to facilitate follow-up communications.
- Specify the provider specialty related to the medication request in the appropriate section.
- Detail the diagnosis for which the drug is requested. Be as precise as possible to support the exception request.
- List any medication history relevant to the diagnosis. Include drug names and dates to provide context for the request. If there is none, indicate 'N/A.'
- Add any additional supporting medical information that could assist in the review process in the space provided.
- Once all fields are filled, ensure to review the entire form for completeness. After verification, save the changes, download, print, or share the form as needed.
Complete the FutureScripts Non-Formulary Exception Request Form online today for efficient processing of your request.
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.
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