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Get Non-formulary Medication Prior Authorization Form
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How to fill out the NON-FORMULARY MEDICATION PRIOR AUTHORIZATION FORM online
Completing the NON-FORMULARY MEDICATION PRIOR AUTHORIZATION FORM is essential for patients needing medications not listed on their insurance formulary. This guide will provide clear, step-by-step instructions to help users fill out the form effectively and submit it online.
Follow the steps to complete the form accurately.
- Click the ‘Get Form’ button to access the NON-FORMULARY MEDICATION PRIOR AUTHORIZATION FORM in the online editor.
- Enter the patient information in the designated fields, including the patient’s name, member ID number, and date of birth.
- Fill out the physician information section with the requesting physician’s name, specialty, office fax number, office phone number, office contact name, and office address.
- Provide the requested drug information, including the drug name, strength, dosing frequency, expected length of therapy, and quantity.
- Indicate the date of request and answer the questions regarding the patient's diagnosis, medication trials, and any contraindications, providing detailed explanations as needed.
- If applicable, check 'Yes' or 'No' for each question regarding reauthorization, prior medication trials, and clinical efficacy.
- In the additional comments section, provide any further required information that may support the authorization request.
- Obtain the prescriber’s signature and date after completing the form. Ensure all information is accurate.
- After completing the form, save your changes, download or print the form as needed, and then fax it to Coventry Health Care of Florida at 1-877-215-4100.
Take action now and start filling out the NON-FORMULARY MEDICATION PRIOR AUTHORIZATION FORM online to ensure timely submission.
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.
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