Form DHS-3641-ENG Advance Member Notice of Noncovered Prescription - Minnesota

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What Is Form DHS-3641-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is the DHS-3641-ENG form?
A: The DHS-3641-ENG form is the Advance Member Notice of Noncovered Prescription specific to Minnesota.

Q: What is the purpose of the DHS-3641-ENG form?
A: The purpose of the form is to provide advance notice to members in Minnesota when a prescription drug is not covered by their plan or requires prior authorization.

Q: Who is required to use the DHS-3641-ENG form?
A: Healthcare providers and pharmacies in Minnesota are required to use the form to notify members of noncovered prescriptions.

Q: What information is included in the DHS-3641-ENG form?
A: The form includes details about the noncovered prescription, such as the drug's name, strength, quantity, and reason for noncoverage.

Q: How is the DHS-3641-ENG form utilized?
A: The form is given to the member or their representative to inform them of the noncoverage, giving them an opportunity to discuss alternative options with their healthcare provider.

Form Details:

Released on August 1, 2018;
The latest edition provided by the Minnesota Department of Human Services;
Easy to use and ready to print;
Quick to customize;
Compatible with most PDF-viewing applications;
Fill out the form in our online filing application.

Download a fillable version of Form DHS-3641-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.