01. Edit your kaiser formulary online
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Non-Formulary Prescription Form - Kaiser Permanente - Community ... - providers kp 2026
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02. Sign it in a few clicks
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03. Share your form with others
Send kaiser formulary 2023 via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out Non-Formulary Prescription Form - Kaiser Permanente - Community ... - providers kp with our platform
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Member Name and Kaiser Permanente Health Record Number at the top of the form.
- Fill in the Date of Birth (DOB) and provide your Prescriber’s Name, Phone number, Fax number, and Office Address in the designated fields.
- Indicate the Diagnosis or Indication for the Non-formulary drug. If applicable, check the box if the member will pay full retail price for this prescription.
- Complete any relevant sections regarding health record documentation, including lack of efficacy or intolerable side effects with formulary medications.
- Write down the Non-Formulary Prescription details below, ensuring to specify a pharmacy where the patient desires to pick up their prescription.
- Finally, have the prescriber sign and date the form before submission.
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See more kaiser formulary versions
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2009 | 4 Satisfied (42 Votes) |
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Plan pharmacy at prices charged to members for non-covered drugs. For more information on our prescription drug FEHB formulary, visit kp.org/formulary orRead more
determination that a non-formulary Prescription Drug is not covered, you may file a grievance as described in the. Dispute Resolution section. ContinuityRead more