Get Formulary Exception Request Form - Independent Health

Navigating the Formulary Exception Request Form for Independent Health can seem complex, but this guide will provide you with clear steps to ensure a smooth submission process. By following these instructions, you can effectively fill out the required information to assist in your request.

Follow the steps to successfully complete the Formulary Exception Request Form.

1. Press the ‘Get Form’ button to access the Formulary Exception Request Form, opening it in your preferred editor.
2. Begin by filling out the patient information section. Provide the patient's first name, last name, date of birth, and member ID. Indicate if the patient is transitioning from a facility by selecting 'Yes' or 'No' and include the facility name if applicable.
3. In the provider information section, enter the provider's first name, last name, NPI number, address, phone number, fax number, office contact, and specialty.
4. Complete the medication/medical and dispensing information section. Fill in the medication name, strength, diagnosis code (ICD9), frequency, quantity, and route of administration. Specify details regarding the provider's involvement in administering the medication and indicate if there are refill requests.
5. Answer the questions regarding the medication’s status. Indicate whether it is a new medication or a continuation of previous therapy. Provide relevant information for dose titration, FDA approved indications, treatment failures, or contraindications based on prior medications.
6. Attach any supporting documentation, such as lab results or medical records that justify the request. Ensure that all required clinical information is included in the designated box.
7. Review all information for accuracy and completeness. Then, the prescriber must sign the form, date it, and ensure any documentation is also attached.
8. Once everything is filled out correctly, you can save your changes, download the completed form, print it, or share it as necessary.

Complete your Formulary Exception Request Form online today to ensure efficient processing of your request.