Get Non-formulary Prescription Form - Kaiser Permanente - Community ... - Providers Kp

Filling out the Non-Formulary Prescription Form is a crucial step for prescribers seeking to request coverage for medications not included in the Kaiser Permanente Drug Formulary. This guide provides clear and detailed instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the section labeled 'Member Name', print the full name of the person for whom the prescription is being filled.
3. Enter the Kaiser Permanente Health Record Number and Date of Birth in the provided fields.
4. In the 'Prescriber Name' section, print or stamp the name of the prescribing professional.
5. Provide the prescriber’s phone number and fax number for any necessary follow-ups.
6. Fill in the office address of the prescriber accurately.
7. Describe the diagnosis or the indication for the requested non-formulary medication.
8. If applicable, check the box indicating if the member will pay the full retail price for the non-formulary prescription.
9. Indicate whether health record documentation exists for the patient by checking 'YES' or 'NO' for each relevant item such as lack of efficacy or intolerable side effects with formulary medications.
10. List any formulary drugs used or considered for this diagnosis, along with responses to treatment.
11. Write the non-formulary prescription details below, ensuring only one prescription per form and a recommended supply of up to 30 days for initial therapy.
12. Select the pharmacy where the patient wishes to pick up the prescription.
13. Complete the DEA number field if applicable and include the prescriber’s signature along with the date.
14. Once all sections are filled, review the form for accuracy before submitting.
15. Submit the completed form via fax to 404-467-2731 or contact 404-365-4159 for real-time review.

Complete your non-formulary prescription form online to ensure timely processing of medications outside the Kaiser Permanente formulary.