About This Worksheet
Worksheet to document clinical justification for formulary exceptions including failed medication trials and adverse reactions.
This worksheet helps you organize and calculate the key information for drug formulary exception worksheet. Fill in each section carefully. Use the calculation areas to verify your numbers before transferring them to the official form.
How to Complete This Worksheet
- Print this worksheet or use it on screen.
- Complete each section in order.
- Use a calculator for all math. Do not estimate.
- Double-check every calculation before moving to the next section.
- Transfer final figures to your official form when complete.
- Keep this worksheet with your records.
Drug Formulary Exception Tracking
Record your data for drug formulary exception worksheet below.
Enter the relevant figure for drug. Use official records.
Enter the relevant figure for formulary. Use official records.
Enter the relevant figure for exception. Use official records.
Enter the relevant figure for worksheet. Use official records.
Your Information
Enter your details as they appear on your official documents.
As it appears on your government ID.
Today's date, MM/DD/YYYY.
From prior drug formulary exception worksheet filings. Write N/A if none.
Additional Notes
Record any other information relevant to your drug formulary exception worksheet calculations.
Verification
Before transferring figures to your official form, confirm:
- All figures are accurate and match your source documents.
- All calculations have been double-checked with a calculator.
- Names and dates match your official identification.
- Information is consistent with requirements for drug formulary exception worksheet.