Get Non-formulary Medications - Upmc Health Plan

Filling out the Non-Formulary Medications - UPMC Health Plan form is essential for obtaining medications that are not listed on the standard formulary. This guide will walk you through each section of the form, providing clear instructions to ensure a smooth submission process.

Follow the steps to successfully complete the form online.

1. Press ‘Get Form’ button to access the Non-Formulary Medications - UPMC Health Plan form and open it for editing.
2. Provide the office contact details including provider specialty, first name, last name, phone number, fax number, and NPI number. Ensure all information is accurate and complete.
3. Enter the patient’s information by filling in their name, UPMC Health Plan ID number, date of birth, age, and the medication requested along with its strength.
4. Specify the frequency and quantity to be dispensed, selecting either 'Brand' or 'Generic'. Make sure to indicate whether this is a new or ongoing medication.
5. If the medication is ongoing, include the date it was started and state if there has been an improvement while on therapy.
6. Fill out the diagnosis section and indicate the place of administration, selecting from options such as physician's office, hospital, facility, or patient home. If applicable, provide the necessary hospital or facility information.
7. Select how the drug will be billed, either medically using a JCODE or at a pharmacy, and include the JCODE if relevant.
8. Detail the history of medications used for the condition, including past medications tried, their start and end dates, strengths, frequencies, and reasons for failure or discontinuation.
9. Use the additional information section to provide any other pertinent details that could support the request.
10. Once all sections are completed, save your changes, and proceed to download, print, or share the form as needed.

Complete your Non-Formulary Medications - UPMC Health Plan form online today to expedite your request.