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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
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- Completing the online Non-Formulary Medication Request Form here,
OR - Downloading and completing the NON-FORMULARY DRUG REQUEST FORM (PDF) and faxing to 512-901-9763.
- Completing the online Non-Formulary Medication Request Form here,
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- 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.
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- Pharmacy staff will send a fax disposition back to the Office Contact Person.