Get Formulary Exceptions Non-formulary Drugs And Quantity

This guide provides detailed instructions on how to complete the Formulary Exceptions Non-Formulary Drugs And Quantity form online. By following these steps, users can efficiently submit a request for coverage of a non-formulary drug or request a quantity above the specified limit.

Follow the steps to fill out the Formulary Exceptions form online.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Fill in the member and provider information section. This includes entering the HPHC member's name, member’s HPHC ID number, provider's name, provider's specialty, and the pharmacy used by the member.
3. Enter the DEA number if applicable, and indicate whether the provider is an HPHC-affiliated physician by selecting YES or NO.
4. Provide the provider's contact telephone number and fax number, as well as the member's date of birth in mm-dd-yy format.
5. In the clinical information section, specify the requested drug, its strength, dosage, quantity per month, and the length of treatment.
6. Complete the dosage form and provide the diagnosis related to the medication request.
7. Document the medical necessity by answering the following: 1. Provide a detailed reason for the medication request. 2. List other medications that have been tried or failed. 3. Include any other pertinent information related to this request.
8. Once all sections are filled, review the form for completeness and accuracy.
9. Depending on your preference, save the changes, download, print, or share the completed form for submission.

Complete your Formulary Exceptions Non-Formulary Drugs And Quantity request online today.