[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288919-105":53,"doc-detail-288919-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","non-formulary-prescription-request-prior-authorization","Non-Formulary Prescription Request - Prior Authorization","","Non-formulary prescription requests specify an approval pathway when formulary alternatives exist. Prior authorization may be granted, typically with a one-year approval duration, based on defined approval criteria tied to the requested product type and clinical circumstances. The criteria require documented trials of formulary options, evidence of inadequate response or intolerance (including required documentation details), consideration of inactive ingredients for combination products, and clinical reasons when an alternative dosage form exists. Requests may also rely on FDA-labeled or accepted off-label sources and exclude certain plan benefit indications.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/non-formulary-prescription-request-prior-authorization/288919/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/non-formulary-prescription-request-prior-authorization/288919.png","ImageObject",442,249,{"name":88,"@type":89},"Valentina","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-08","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the approval duration for a non-formulary prescription request?","Question",{"text":109,"@type":110},"The request indicates Prior Authorization with an approval duration of 1 year.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What documentation is required when formulary alternatives are available?",{"text":114,"@type":110},"The individual must trial and have an inadequate response or intolerance to at least two formulary alternatives, with confirmations describing the inadequate response or intolerance for each product, or confirmation of FDA MedWatch submission for each product.",{"name":116,"@type":107,"acceptedAnswer":117},"When can a non-formulary medication be approved without formulary or dosage form alternatives?",{"text":118,"@type":110},"It may be approved based on FDA-approved labeled indications or accepted compendia off-label indications, and it is subject to exclusions for certain non-covered benefit indications by the health plan.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},288919,1790317213,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":101,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":79},13056703020460,"https://ap-avatar.wpscdn.com/avatar/be000253dac470eee5d?_k=1778207105932848923","Non-Formulary Prescription Request  \n\n| Override(s) | Approval Duration |\n| --- | --- |\n| Prior Authorization | 1 year |\n\n\n| Medications | Quantity Limit |\n| --- | --- |\n| Non-Formulary Prescription Requests | May be subject to quantity limit |\n\nAPPROVAL CRITERIA  \nThe individual must meet the following criteria to receive a non-formulary product if formulary alternative(s) are available:  \nI. If the requested product is a brand or generic product without an FDA approved generic therapeutic equivalent or interchangeable biosimilar available on formulary:  \nA. Individual has had a trial and inadequate response or intolerance to at least two formulary alternative products FDA approved for the same condition and within the same therapeutic class; AND  \n1. Confirmation has been provided describing the nature of the inadequate response or intolerance for each product;  \nOR  \n2. Confirmation has been provided that a completed FDA MedWatch Adverse Event  \nReporting Form has been submitted to the FDA for each product;  \nOR  \nB. If the request is for a combination product for which the individual components are available as generic and/or preferred formulary products at similar doses, then the individual has had a trial and inadequate response or intolerance to the individual components that is likely due to an inactive ingredient; OR  \nC. If the request is for a product with an available alternative dosage form for the same active ingredient and same FDA approved indication on formulary, then confirmation has been provided indicating the clinical reason why the individual is unable to take an alternative formulary dosage form; OR  \nD. If only one formulary product is available in the same therapeutic class, the individual has had a trial of and inadequate response or intolerance to the one formulary product for the same condition and within the same therapeutic class.  \nII. Any Non-Formulary medication without formulary or dosage form alternatives may be approved based on FDA approved labeled indications or accepted compendia off-label indications (e.g. AHFS, Micromedex, NCCN, etc. ) .  \nNOTE:  \nIf the requested product is being prescribed for an indication that is an excluded benefit by the applicable health plan (e.g. , weight loss, erectile dysfunction, fertility, cosmetic, hair loss, medical foods) , the non-formulary exception process will not apply.  \nKey References:  \n1. DailyMed. Package inserts. U.S. National Library of Medicine, National Institutes of Health website.  \n[http://dailymed.nlm.nih.gov/dailymed/about.cfm](http://dailymed.nlm.nih.gov/dailymed/about.cfm).  \n2. DrugPoints® System [electronic version] . Truven Health Analytics, Greenwood Village, CO. Updated periodically.  \n3. Lexi-Comp ONLINE ™ with AHFS ™ , Hudson, Ohio: Lexi-Comp, Inc. ; Updated periodically.  \nFederal and state laws or requirements, contract language, and Plan utilization management programs or policies may take precedence over the application of this clinical criteria.  \nNo part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.  \nMultisource Brand (MSB) Agents  \n\n| Override(s) | Approval Duration |\n| --- | --- |\n| Prior Authorization | 1 year |\n\n\n| Medications-Multisource Brand (MSB) Agents |\n| --- |\n| ABILIFY |\n| ACIPHEX |\n| ADCIRCA |\n| ADDERALL |\n| ADDERALL XR |\n| AFINITOR |\n| AFINITOR DISPERZ |\n| AMBIEN |\n| AMBIEN CR |\n| AMPYRA |\n| APTENSIO XR |\n| AUBAGIO |\n| BUPHENYL |\n| CARBAGLU |\n| CELEBREX |\n| CELEXA |\n| CIALIS |\n| CLOZARIL |\n| CONCERTA |\n| COPAXONE |\n| CORLANOR |\n| CRESTOR |\n| CYMBALTA |\n| DAYTRANA |\n| DESOXYN |\n| DEXEDRINE |\n| DEXILANT |\n| EFFEXOR XR |\n| ELIDEL |\n| EMFLAZA |\n| ENDARI |\n| ESBRIET |\n| EVEKEO |\n| EXJADE |\n\n| FIRAZYR |\n| --- |\n| FOCALIN |\n| FOCALIN XR |\n| FORFIVO XL |\n| FROVA |\n| GEODON |\n| GILENYA |\n| GLEEVEC |\n| HALCION |\n| HALDOL DECANOATE 100 |\n| HALDOL DECANOATE 50 ","cbCaigwVYx1Q4jXF","https://ap.wps.com/l/cbCaigwVYx1Q4jXF","pdf",424540,"English","# Non-Formulary Prescription Request\n## Override(s) and Approval Duration\n## Medications and Quantity Limit\n## Approval Criteria","[{\"question\":\"What is the approval duration for a non-formulary prescription request?\",\"answer\":\"The request indicates Prior Authorization with an approval duration of 1 year.\"},{\"question\":\"What documentation is required when formulary alternatives are available?\",\"answer\":\"The individual must trial and have an inadequate response or intolerance to at least two formulary alternatives, with confirmations describing the inadequate response or intolerance for each product, or confirmation of FDA MedWatch submission for each product.\"},{\"question\":\"When can a non-formulary medication be approved without formulary or dosage form alternatives?\",\"answer\":\"It may be approved based on FDA-approved labeled indications or accepted compendia off-label indications, and it is subject to exclusions for certain non-covered benefit indications by the health plan.\"}]","Non-Formulary Prescription Request - Prior Authorization | PDF",1789634213]