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Non-Formulary Medication Request

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  • Prescribers can request approval for non-formulary medications for MAP and MAP BASIC members.
  • Prescribers can submit a Non-Formulary Medication Request by
    1. Completing the online Non-Formulary Medication Request Form here,
    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.