Edit, Download, and Sign the Highmark Wholecare Non-Formulary Medication Form
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How do I fill this out?
To fill out this form, start by collecting all required information about the member and medication. Ensure that all entries are completed accurately, including medical history and billing details. Finally, review the completed form for clarity before submission.
How to fill out the Highmark Wholecare Non-Formulary Medication Form?
1
Gather all necessary information regarding the member.
2
Complete each section of the form methodically.
3
Include relevant medical history and previous therapy information.
4
Verify your information and ensure everything is accurate.
5
Submit the form via fax or phone as instructed.
Who needs the Highmark Wholecare Non-Formulary Medication Form?
1
Healthcare providers who prescribe medication and need prior authorization.
2
Patients seeking coverage for medications not listed on formulary.
3
Pharmacies that require documentation for non-formulary drugs.
4
Insurance coordinators managing member benefits and requests.
5
Healthcare facilities needing formal authorization for medication.
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What are the instructions for submitting this form?
To submit this form, please fax it to Pharmacy Services at (888) 245-2049. For any inquiries, you may call Pharmacy Services at (800) 392-1147 during business hours, Monday through Friday, from 8:30 am to 5:00 pm. Ensure all required documentation is included with your submission.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, ensure all submissions align with any annual policy updates. Check with Highmark Wholecare for specific dates. Deadlines may affect coverage determinations and necessary approvals.
What is the purpose of this form?
The purpose of this form is to authorize and document requests for non-formulary medications. Healthcare providers must complete the form with accurate member and medication information. This ensures that patient needs are met while adhering to insurance policies.
Tell me about this form and its components and fields line-by-line.
- 1. Provider Information: Includes details about the prescribing provider and their contact information.
- 2. Member Information: Personal details about the member, including name, DOB, and medical history.
- 3. Requested Drug Information: Specifics about the medication requested, including dosage and frequency.
- 4. Billing Information: Financial details necessary for processing the request.
- 5. Medical History: Relevant medical history that supports the therapy request.
- 6. Current or Previous Therapy: Information about any past therapies related to the request.
What happens if I fail to submit this form?
If this form is not submitted correctly, the authorization for medication may be denied. This can lead to delays in receiving necessary treatment and potentially impacting the member's health.
- Delay in Treatment: A failure to submit may delay necessary medications.
- Denial of Coverage: Unauthorized medications may lead to out-of-pocket costs.
- Increased Health Risks: Missing medication can result in worsened health outcomes.
How do I know when to use this form?
- 1. Non-Formulary Medication Request: Required when a prescribed medication is not available on the formulary.
- 2. Prior Authorization: Necessary for any non-formulary medications to obtain approval.
- 3. Insurance Verification: Used to confirm that coverage is applicable for medications.
Frequently Asked Questions
How do I submit this form?
You can submit this form by faxing it to the designated Pharmacy Services number.
What information do I need?
You will need member details, medication information, and prescribing provider information.
Can I edit this PDF?
Yes, you can easily edit the PDF using our built-in editor.
Is there a deadline for submission?
Ensure timely submission before the member's medication is needed.
How can I share this PDF?
Use our sharing tools to send the PDF via email or social media.
Where do I find my NPI number?
Your NPI can be found through your healthcare organization’s documentation.
What if the information is incorrect?
You can edit the information directly in the PDF before submission.
Can I save the edited PDF?
Yes, after editing, you can download the final version of your PDF.
What happens if I don't submit this form?
Failure to submit may delay medication approval and coverage.
Who should I contact if I have questions?
Contact the Pharmacy Services hotline for assistance.
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