Non-Formulary Medication Request

• Prescribers can request approval for non-formulary medications for MAP and MAP BASIC members.
• Prescribers can submit a Non-Formulary Medication Request by

1. 1. Completing the online Non-Formulary Medication Request Form here,
      OR
   2. Downloading and completing the NON-FORMULARY DRUG REQUEST FORM (PDF) and faxing to 512-901-9763.

• • • Complete the Medication Override Request Form to request an evaluation for non-formulary medications and interim fills
    • Use a separate form for each request. Please attach any additional supporting documentation.
    • Fax the form(s) to 512-901-9763.

• Pharmacy staff will send a fax disposition back to the Office Contact Person.