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  • Non-formulary Drug Exception Form - Riverside Health

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NON?FORMULARY/BRAND MEDICALLY NECESSARY DRUG EXCEPTION FORM FAX COMPLETED FORM TO: (410) 849?0617 First Name Allergies Pharmacy Name SECTION 1 ? MEMBER INFORMATION Last Name Date of Birth Member ID.

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A formulary is a list of drugs and supplies covered by a health insurance plan, and each plan has its own specific formulary. Non-formulary drugs are those that are not covered or that are covered a higher rate than formulary drugs.

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

Understanding your prescription medication coverage Drug formularies vary from plan to plan. If the prescription medications you take are not included in your insurance plan's formulary, you may be responsible for paying for them out of pocket.

Most plans require that your doctor submit a formulary exception on your behalf. The doctor will need to send paperwork to your health plan indicating the reason that you can't take the preferred medications and must have one that is not currently on the formulary.

Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollee's prescriber must submit a supporting statement to the plan sponsor supporting the request.

An exception procedure can be used by prescribers and patients to request coverage for drugs that are not included on a plan's drug formulary. Through this administrative process, a plan can agree to cover medically necessary nonformulary drugs on a case-by-case basis.

A drug formulary is a list of all drugs, both generic and brand name, that are covered by your health plan. The purpose of the drug formulary is to direct members to the least costly medication that is most effective in treating their condition.

If you need a drug that is not on your health plan's formulary, you must get your plan's approval or pay for the drug yourself. Your doctor should ask the plan for approval. In certain cases, a health plan may be required to cover a drug that is not on your plan's formulary.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
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