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Get Pharmacy Prior Authorization Request Form - Caresource
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How to fill out the Pharmacy Prior Authorization Request Form - CareSource online
Filling out the Pharmacy Prior Authorization Request Form - CareSource online can be straightforward when you follow the right steps. This guide will assist you in completing the form accurately, ensuring all necessary information is included for a successful submission.
Follow the steps to fill out the form correctly.
- Click ‘Get Form’ button to obtain the Pharmacy Prior Authorization Request Form and open it for completion.
- Begin by providing the patient information. Fill in the patient's name, date, Humana - CareSource ID, date of birth, gender, medication allergies, pharmacy name, and pharmacy phone number.
- Next, move to the provider information section. Enter the prescriber's name, NPI number, DEA number, specialty, address, office fax, phone number, and contact name.
- In the medication requested section, include the drug name, strength, directions (Sig), duration of therapy (days and months), quantity, HbA1c with date (if applicable), diagnosis, and whether the patient is currently treated on this medication along with the start date if applicable.
- Provide details in the medical justification section. List any other relevant medications the patient has tried, including their strength, quantities, directions, dates of use, and reasons for discontinuation.
- Add any relevant medical rationale for the request or additional clinical information. It is essential to attach lab results and chart notes if available.
- Finally, ensure that the provider's signature and date are included. Review the form for completeness, as missing or illegible information will result in the request being returned.
- Once all sections are filled out correctly, you can save changes, download, print, or share the completed form as needed.
Complete your Pharmacy Prior Authorization Request Form online today to ensure a smooth approval process.
A prior authorization (PA), sometimes referred to as a pre-authorization, is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure.
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