PRIOR AUTHORIZATION REQUEST FORM EOC ID: SW Exchange Non-Formulary Drug Request Phone: 800-728-7947 Fax back to: 866-880-4532 Scott & White Prescription Services manages the pharmacy drug benefit.
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How to fill out the Non-Formulary Drug Request Form - Swhp online
Filling out the Non-Formulary Drug Request Form - Swhp online is a straightforward process that ensures your request for drug coverage is submitted correctly. This guide provides clear, step-by-step instructions to assist you in completing the form efficiently.
Follow the steps to complete the Non-Formulary Drug Request Form - Swhp online
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling in the patient details. Enter the patient’s name, date of birth, and primary phone number. Make sure all information is accurate to prevent delays.
- Provide the prescriber’s information. Include the prescriber’s name, contact phone number, and NPI. This is essential for verification.
- Input the member or subscriber number and group number associated with the patient's insurance. This helps to identify the insurance coverage.
- Fill out the addresses correctly, including the street address, city, state, and ZIP code, for both the patient and prescriber.
- Indicate whether the request is expedited or urgent by checking the appropriate box, if applicable.
- Enter the drug name and strength being requested along with detailed directions for administration.
- Complete the diagnosis field along with the corresponding ICD9 code, ensuring that it accurately reflects the patient's condition.
- Provide a clear reason for the drug request, including any relevant medical history or documentation that supports the approval.
- List any formulary drugs that the patient has already tried and failed for this condition, as well as those they cannot take, including rationale.
- Add any additional comments that may aid in the review process.
- Finally, ensure the prescriber signs and dates the form before submission.
- Once all fields are filled out, review the form for completeness and accuracy. Save changes, then download or print the completed form for submission.
Complete the Non-Formulary Drug Request Form - Swhp online today to ensure your request is processed without delay.
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What does non-formulary mean for drug coverage?
Meaning. Non-formulary/Non-covered. Non-Formulary Drugs are not covered on the formulary drug list. An exception may be requested and is subject to review by the plan and is based on Pharmacy policy. Prior Authorization.
What is a non-formulary exception 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.
What is the use of non-formulary item request form?
Often, non-formulary drug request forms are used to request a nonformulary drug. The form should contain the patient basic information, the rationale of use, the volume of drugs needed.
What does non-formulary request mean?
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.
What is a non-formulary exception?
NON-FORMULARY EXCEPTION CRITERIA FOR APPROVAL The member must have tried at least three alternative formulary medications that have a similar mechanism of action as the requested medication AND the member either did not respond to or did not tolerate the formulary alternative medications.
What happens if a drug is non-formulary?
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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