Get Non-formulary Form

Filling out the Non-Formulary Form online can streamline the process of requesting necessary medications not included in the standard formulary. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete your Non-Formulary Form online.

1. Press the ‘Get Form’ button to access the Non-Formulary Form and open it in your online editor.
2. Begin by filling in the office contact details, including the provider specialty, first name, last name, phone number, and fax number.
3. Provide the patient’s information, including their name, UPMC Health Plan ID number, age, date of birth, and specify the drug requested including strength and frequency.
4. Indicate the quantity to be dispensed, selecting either 'Brand' or 'Generic,' as applicable to avoid unnecessary substitutions.
5. Clarify if the request is for a new medication or ongoing medication, and provide the diagnosis with the start date if it is ongoing.
6. Detail the patient’s medical history, including baseline and current cholesterol and LDL levels, LDL goals, and any risk factors that may be relevant.
7. List any cholesterol-lowering medications the member has previously tried, alongside details about any adverse reactions, including reasons for discontinuation.
8. In the provided space, include any additional relevant information that should be considered during the review process.
9. Once all fields are completed, review the information for accuracy and completeness before saving your changes. You may then choose to download, print, or share the completed form.

Take action by completing your Non-Formulary Form online today!