Silverscript Procrit Pa Form PDF Details

In the landscape of healthcare and prescription drug coverage, navigating the requirements for obtaining coverage for non-formulary drugs is a complex process that demands precise attention to detailed protocols. At the heart of these protocols is the utilization of specific forms designed to facilitate the review and approval process, exemplifying the Silverscript Procrit Pa form—a crucial document for healthcare providers seeking to secure coverage for medications not listed on a patient's formulary. This form serves as a comprehensive tool, enabling prescribers to submit requests for coverage exceptions by providing necessary patient information, clinical justification for the non-formulary drug, and a detailed account of previous treatments and their outcomes. It outlines a clear pathway for submitting requests, emphasizing the importance of furnishing complete and accurate information to avoid delays in the review process. With provisions for both standard and expedited review processes, the form highlights the urgency with which certain cases need to be addressed, particularly when a patient's life or health is at serious risk. Additionally, it underscores the stringent privacy regulations governing the handling of patients' health information, aligning with HIPAA requirements to ensure the confidentiality and security of personal health data. This introductory exposition aims to provide an overview of the major aspects of the Silverscript Procrit Pa form, shedding light on its pivotal role in the prescription drug coverage ecosystem.

Form NameSilverscript Procrit Pa Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesformulary form, silverscript pa form, silverscript prior auth form, silverscript forms

Form Preview Example

Fax completed form to: 1-855-633-7673

Questions, please call: 1-855-344-0930

24 hours a day 7 days a week (TTY users call: 711)

Important Information about Prescription Drug Coverage



Re: Request for Coverage of a Non-Formulary Drug: Please respond.

Please complete the attached Request for Coverage of a Non-Formulary Drug Form.

To prevent delays in the review process please complete all requested fields.

Completed forms should be faxed to: 1-855-633-7673. It is not necessary to fax this cover page.

Information about this Request for Coverage of a Non-Formulary Drug

Use this form to request coverage of a drug that is not on the formulary. To process this request, documentation that all formulary alternatives would not be as effective or would have adverse effects is required. Please provide clinical information or other evidence supporting the medical necessity of the non-formulary drug, including previous formulary drugs attempted for this patient's condition. If the formulary exception is approved, it will be reimbursed at the highest brand tier copay for the calendar year.

You can make an expedited request by indicating this at the top of the attached form. If you request an expedited review and sign the attached form, you certify that applying the 72 hour standard review time frame may seriously jeopardize the life or health of the member or the member's ability to regain maximum function.

Information on the attached form is protected health information and subject to all privacy and security regulations under HIPAA.

Member privacy is important to us. Our employees are trained regarding the appropriate way to handle our members' private health information.

CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and/or privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments.

5246-24762a 011912

Silverscript® Insurance Company

Fax completed form to: 1-855-633-7673


Questions, please call: 1-855-344-0930


24 hours a day 7 days a week


(TTY users call: 711)

Request for Coverage of a Non-Formulary Drug

Patient Information


Member ID -

Medicare ID

Date of Birth


M /F




























Nursing Home Resident




Home care patient?





Prescriber and Pharmacy Information

















































































































































































































































































Pharmacy name
















































































































All items below this line are for Physician Use Only





Information for Requested Drug









Drug Name: ----------------------------------------------------







Drug Requested is (circle one): Brand /Generic



Dosage form:


Qty per 30 days:


Drug is (circle one):Newly prescribed /Refill





























ICD-10 Code:



Standard Reviews will be completed in under 72 hours. An expedited















review is available if you certify that a standard review time frame will seriously jeopardize the health of your patient. To request an expedited review, simply indicate this at the top of this page.

Request for Coverage of a Non-Formulary Drug Criteria

Medical Justification: Please provide medical justification for the non-formulary drug exception request. Please address why all formulary alternatives on any tier of the formulary for treatment of the same condition would not be effective or would cause adverse effects. List previous drugs and doses attempted for this patient, condition and dates or approximate dates or duration of treatment (if known). Document adverse effects requiring discontinuation and/or reason for perceived ineffectiveness. Attach additional pages if necessary.

If all formulary agents would not be effective, please specify prior treatment failures:-------------------




If all formulary agents would have adverse effects, please specify prior adverse effect history:---------




If patient preference for nonformulary drug, please provide your clinical rationale:---------------------



If no available formulary alternatives have been previously tried, please check this box.

I attest that the information provided on this form is true and accurate as of this date:

Prescriber's signature:





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Step 1: Click the button "Get Form Here".

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For you to prepare the document, enter the details the platform will ask you to for each of the appropriate sections:

silverscript prior auth empty fields to fill in

Type in the essential details in Request for Coverage of a, Prescriber and Pharmacy, YES NO YES NO, M F, ZIP, Fax, Fax, ZIP, and All items below this line are for area.

Filling in silverscript prior auth step 2

Remember to provide the required particulars in the All items below this line are for, Drug is circle one Newly, Qty per days, Dosage form, Diagnosis, Medical Justification Please, If all formulary agents would not, and If all formulary agents would have field.

step 3 to entering details in silverscript prior auth

Inside of section If patient preference for, If no available formulary, I attest that the information, and Date, state the rights and responsibilities.

step 4 to completing silverscript prior auth

Step 3: As soon as you are done, press the "Done" button to export the PDF document.

Step 4: Ensure that you avoid forthcoming complications by producing no less than two duplicates of your file.

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