Get Non-formulary Drug Exception Form - Riverside Health

Filling out the Non-Formulary Drug Exception Form is an essential process for obtaining necessary medications that are not listed on the formulary. This guide provides clear, step-by-step instructions to assist users in completing the form properly and efficiently online.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by completing Section 1 - Member Information. Fill in the first name, last name, date of birth, any known allergies, and type of reactions experienced.
3. Proceed to Section 2 - Pharmacy Information. Provide the name of the pharmacy and their phone number to ensure proper processing.
4. In Section 3 - Prescription Information, enter the drug name and strength requested, the frequency it will be taken, the quantity needed, and the member ID. Specify the requested length of therapy and provide a diagnosis for the requested medication along with the corresponding diagnosis code.
5. Move on to Section 4 - Formulary Drug(s) Information. Attach necessary documentation demonstrating treatment failure or contraindications with a formulary drug. Include the formulary drug name and strength, the date it was tried, and the reason for treatment failure or discontinuation.
6. Complete Section 5 - Additional Clinical Information. Here, include any supporting medical literature, current office notes, and lab data that substantiate the request.
7. In Section 6 - Prescriber Information, provide the prescriber’s name (printed), specialty, office phone number, and office fax number. The prescriber must also sign and date the form.
8. Review Section 7 - Approval Information, which is for Riverside Health internal use only. This section includes options for approval status and enables the prescriber to indicate whether waiting for a decision could seriously harm the member's health.
9. Once all sections are completed, ensure all information is accurate and save your changes. You may also download, print, or share the completed form as needed.

Complete the Non-Formulary Drug Exception Form online to ensure timely access to your necessary medication.