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C (8762) FAX 412-454-7722 PLEASE TYPE OR PRINT NEATLY Please complete all sections of this form AND include details of past relevant medical treatment, which substantiates the need for an exception to using formulary alternatives, i.e. past prescription treatment failures, documented side effects, chart documentation, lab values, etc. Incomplete responses may delay this request. Office Contact: Provider Specialty: Provider First Name: Provider Last Name: Provider Phone: Provider Fax: Pa.

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Non-preferred medications are not covered under the drug formulary, or they may be more expensive than preferred medications. Your health insurance plan creates a drug formulary to provide you access to the safest, most effective treatments.

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.

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.

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.

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.

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.

The most commonly prescribed classes of non-formulary drugs were immunobiologicals (vaccines), antiemetics, vitamins, psychotropic drugs, beta blockers, and systemic antimycotics and antibacterials.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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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