Get Silverscript Non-formulary Exception Form 2012
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How to fill out the SilverScript Non-Formulary Exception Form online
The SilverScript Non-Formulary Exception Form is essential for users who need coverage for medications not listed on the formulary. This guide provides clear, step-by-step instructions on how to efficiently complete the form online, ensuring a smooth process for submitting your request.
Follow the steps to fill out the SilverScript Non-Formulary Exception Form online
- Press the ‘Get Form’ button to access the SilverScript Non-Formulary Exception Form and open it in your document editor.
- Begin filling in the patient information section. Include the patient's name, member ID, Medicare ID, date of birth, sex, and address details.
- Next, provide the prescriber and pharmacy information, including the prescriber's name, specialty, DEA, NPI, and the address of the pharmacy.
- In the drug information section, specify the drug name, whether it is brand or generic, the strength, dosage form, quantity per 30 days, and if it is newly prescribed or a refill.
- Fill in the directions for use, diagnosis, and ICD-9 code if applicable.
- If an expedited review is required, ensure to indicate this at the top of the form and certify the necessity.
- Provide medical justification for the non-formulary drug exception request, explaining why formulary alternatives are not suitable.
- Ensure the prescriber signs and dates the form to attest the accuracy of the information provided.
- Once all sections are completed, review the form for accuracy. Users can then save the changes, download, or print the form for submission.
Start filling out your SilverScript Non-Formulary Exception Form online today for timely processing.
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If your medication is not on the formulary, you should first consult your healthcare provider for alternatives. If your provider determines that the non-formulary drug is essential for your health, they can help you fill out the SilverScript Non-Formulary Exception Form. This process provides a clear path for requesting coverage from your insurance company. Don't hesitate to reach out to your insurance representative for guidance on next steps.