Get Caresource Pharmacy Prior Authorization Request Form 2013-2025

Filling out the CareSource Pharmacy Prior Authorization Request Form is an important process for ensuring that the necessary medications are approved for patients. This guide provides clear instructions on how to complete the form accurately and effectively, helping users navigate the online process with confidence.

Follow the steps to fill out the form correctly

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the patient's information, including their name, date of request, CareSource ID, date of birth, gender, and any medication allergies. Make sure this information is accurate to avoid processing delays.
3. Fill in the pharmacy details, such as the pharmacy name and contact information, including the pharmacy phone number.
4. Provide the prescriber information, including their name, NPI number, DEA number, specialty, address, office fax, phone number, and the contact person's name.
5. In the medication requested section, enter the drug name, strength, directions for use (Sig), duration of therapy in days and months, and the quantity to be prescribed.
6. If applicable, enter the latest HBA1C result date. Describe the diagnosis relevant to the medication request.
7. Indicate whether the patient is currently treated with the medication. If yes, provide the date treatment started. If no, select the corresponding option.
8. In the medical justification section, list any previous medications tried, along with their strengths, quantities, directions, treatment dates, and reasons for discontinuation.
9. Provide relevant medical rationale for the request and include any additional clinical information, such as lab results and chart notes as attachments.
10. Ensure the provider signature and date are completed at the bottom of the form. Confirm that all sections are filled out completely, as incomplete forms will be returned.
11. Save the changes you made to the form. You may then download, print, or share the completed form as necessary.

Start completing the CareSource Pharmacy Prior Authorization Request Form online today to ensure timely medication approval.