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Click ‘Get Form’ to open the Non-Formulary Exception Request in the editor.
Begin by entering the 'Drug Requested' and 'Quantity' in the designated fields. Ensure accuracy as this information is crucial for processing your request.
Fill in the 'Patient ID#', 'DOB', and 'Patient Name' to identify the individual for whom the exception is being requested.
Provide your 'Provider NPI', 'Prescribing Physician', and contact details including 'Office Contact', 'Fax #', and 'Phone #'. This ensures that communication regarding the request is streamlined.
Specify your provider specialty and diagnosis related to the drug request in their respective sections. This information helps justify the need for a non-formulary medication.
Document any relevant medication history, including previous therapies, using drug names and dates. If not applicable, indicate ‘N/A’.
Add any additional supporting medical information that may assist in decision-making within the provided space.
Once completed, review all entries for accuracy before submitting via fax to (888) 671-5285. Your office will receive a response via fax or mail.

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How hard is it to get a formulary exception?

you have pretty good odds of getting the formulary exception approved when it is a continuation of therapy (in your case) vs a new therapy. they will just have to document what youve tried and failed, and how what youre on now is working well for you and usually it is approved when you are already on the medication.

How to get insurance to cover non-formulary drugs?

A formulary exception is a request to your insurance company to cover a non-formulary drug. This request is typically initiated by your provider, who will provide supporting documentation, accompanied by a letter of medical necessity (LMN), to explain why the requested medication is necessary for your treatment.

Do non-formulary drugs count towards deductible?

Non-formulary medicines should be prescribed only when formulary choices are not suitable or have been exhausted. Non-formulary prescribing should not be used to bypass usual NHS commissioned pathways.

What if my drug is not on the formulary?

A doctor may prescribe a non-formulary drug when covered therapies havent been effective for you. If you and your doctor have decided that a non-formulary drug is right for you, your doctor can request approval. Getting approval helps you lower your out-of-pocket costs.

Will insurance cover non-formulary drugs?

You can get an exemption so that you wont have to pay a penalty for not having qualifying health insurance. Some exemptions require an exemption application through Covered California. Other exemptions do not require an application: Instead, you can claim them when you file your state tax return.