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How do I fill this out?
To fill out this form, ensure all sections are completed accurately. Include detailed medical history that supports the need for the requested medication. It is important to provide all necessary documentation to avoid delays.
How to fill out the UPMC Health Plan Non-Formulary Medications Form?
1
Complete patient and provider information.
2
Indicate the drug requested and its details.
3
List past medications and reasons for failures.
4
Provide additional relevant medical information.
5
Submit the form to the appropriate UPMC contacts.
Who needs the UPMC Health Plan Non-Formulary Medications Form?
1
Patients using medications not on the formulary need this to request exceptions.
2
Healthcare providers require this form to obtain necessary authorizations for patients.
3
Pharmacy staff may need this to process medication requests efficiently.
4
Insurance companies use this to assess the validity of medication requests.
5
Care coordinators need to ensure proper medication management for patient care.
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Editing your PDF on PrintFriendly is simple and intuitive. You can make changes to the text fields and adjust the document to your liking. This feature ensures that your form meets your specific needs before submission.
1
Upload the PDF document to PrintFriendly.
2
Select the text or fields you want to edit.
3
Make the necessary changes and adjustments.
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Download the final edited version for submission.
What are the important dates for this form in 2024 and 2025?
It is essential to note that forms must be submitted by the deadlines set forth by UPMC Health Plan. Stay updated on any changes regarding submission dates for 2024 and 2025 to avoid any issues with your medication requests.
What is the purpose of this form?
The UPMC Non-Formulary Medications Prior Authorization Form is designed to allow healthcare providers and patients to request exceptions for medications that aren't on the formulary. It facilitates the communication between providers and the health plan to ensure necessary medications are accessible. This form supports the patient's needs by helping them obtain crucial treatments that their healthcare provider has deemed necessary.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Full name of the patient requiring the medication.
- 2. Provider First Name: First name of the prescribing healthcare provider.
- 3. Drug Requested: The name of the medication being requested.
- 4. Diagnosis: The medical condition that necessitates the requested medication.
- 5. History of Medications: Details of any past medications tried with reasons for discontinuation.
What happens if I fail to submit this form?
If the form is not submitted correctly, it may lead to delays in receiving the necessary medications. Incomplete or incorrect information can result in denial of the request, requiring resubmission of the form.
- Delay in Medication Access: Incomplete forms can delay the approval process for necessary medications.
- Increased Administrative Burden: Providers may face extra work to correct and resubmit forms.
- Possible Denial of Coverage: Incomplete submissions could lead to denial of the requested medication.
How do I know when to use this form?
- 1. Medication Exceptions: When a patient needs a non-formulary medication.
- 2. Prescription Failures: If previously tried medications were unsuccessful.
- 3. Documented Side Effects: When patients experience adverse effects from formulary options.
Frequently Asked Questions
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While saving files is not available, you can download the edited PDF.
Is there a guide for filling out the form?
Yes, thorough instructions are provided on the form itself.
What if I forget to include information?
Incomplete submissions may delay processing, so ensure all details are filled in.
How do I share the PDF?
You can share your edited PDF directly via email or through social media platforms.
Can I use this form for different medications?
Yes, you can use this form to request any non-formulary medication.
What should I do if my medication request is denied?
You may need to appeal the decision and provide additional documentation.
How do I contact UPMC Health Plan Pharmacy Services?
Contact them at 1-800-979-UPMC (8762) for assistance.
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Can I print the filled form directly?
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