Home
Forms Library
Non formulary request form

Non formulary medication request form 2026

non formulary request form Preview on Page 1

See details

4.5 out of 5

56 votes

The document is a Non-Formulary Medication Request Form from the Department of Pharmacy, which must be completed by attending physicians to order and dispense non-formulary drugs. It outlines the requirements for initiating therapy, the potential cost implications, expected delays in drug availability, and the need for clinical justification if formulary alternatives are not suitable.

Here's how it works

01. Edit your non formulary request form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send non formulary request form pdf via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out non formulary medication request form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the non-formulary medication request form in the editor.
Begin by pasting the patient information label in the designated area at the top of the form.
Fill in the 'Date of order' field with the current date to ensure accurate processing.
Enter the 'Name of medication', 'Dose', 'Frequency', and 'Dosage form' as per your prescription details.
Specify the 'Expected duration of therapy' to provide clarity on treatment length.
Indicate the prescriber’s name and include a clinical reason if a formulary therapeutic substitution is not appropriate.
Ensure that the physician signs and stamps the form before submission for pharmacy processing.

Start using our platform today to streamline your non-formulary medication requests for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a non-formulary drug request?

Drugs not listed on the formulary are called non-formulary or excluded drugs. A medication may be excluded from coverage under your pharmacy benefit when it works similarly to another prescription drug or over-the-counter (OTC) medication. Please speak with your provider about medication options.

non formulary medication form

VA non Formulary request form Template non formulary medication Non formulary drug request Non formulary meaning MedStar Family Choice Prior Authorization form non pharmacy MedStar Family Choice pharmacy Prior Authorization Form

Security and compliance

At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

Learn more