Medical Necessity Form For Non-Formulary Or Non-Preferred Medications
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1Member Name: ______________________________ Member ID: ___________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: __________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: ________________
Physician Fax #: _____________________ Pharmacy Name: _________________________Pharmacy Phone: __________________
Horizon NJ Health
Medical Necessity Form for Non-Formulary or Non-Preferred Medications
Questions
Answers
1.
Can a formulary alternative be tried instead?
Yes
No
(If YES, please call a new prescription into the pharmacy for
the formulary alternative. If NO, continue.)
2.
Why is it that the patient cannot switch to an
alternative? If the member cannot switch due to a
contraindication/drug interaction, please specify.
3. What is the patient’s diagnosis?
4.
Has patient tried any alternative medications?
Yes
No
5.
If answer to #4 Yes, ask the following questions:
a.
What alternatives were tried?
1.
Drug Name:____________________________
b.
When were they tried?
______________________________(Note dates tried)
c.
For how long did the member take the
______________________________(How long on the drug?)
alternative(s)?
______________________________(Reason discontinued )
d.
Why were they discontinued? If due to a side
effect or intolerance, please describe.
2.
Drug Name:____________________________
______________________________(Note dates tried)
______________________________(How long on the drug?)
______________________________(Reason discontinued)
6.
Will the member be taking any other medications
Yes
No
concurrently with this drug? If so, please list the
drugs the member will be taking.
Drug
Name(s):__________________________________________
7.
Is the patient currently receiving the medication?
Yes
No
8.
How long has patient been on this drug?
9.
When was the medication last filled?
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
Rev. 03/16
HNJH Fax #: 888-567-0681
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