Get Caresource Pharmacy Prior Authorization Request Form

Filling out the CareSource Pharmacy Prior Authorization Request Form online is essential for ensuring that your medication needs are met efficiently. This guide provides a step-by-step approach to navigate the form, helping you complete it thoroughly and accurately.

Follow the steps to fill out the CareSource Pharmacy Prior Authorization Request Form effectively.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Begin by entering the patient information. Fill in the patient’s name, date, CareSource ID, date of birth, and gender. Ensure that this information is accurate to avoid any processing delays.
3. Input the medication allergies of the patient, along with the name and phone number of the pharmacy where the prescription will be filled.
4. Provide prescriber information in the allotted fields, including the prescriber’s name, NPI number, DEA number, specialty, address, fax number, phone number, and contact name.
5. In the medication requested section, specify the drug name, strength, directions for use (Sig), duration of therapy, quantity, and any relevant HbA1c results with dates.
6. Indicate whether the patient is currently being treated with the medication by selecting 'Yes' or 'No.' If 'Yes,' include the date the treatment started.
7. Detail the medical justification for the request. Include previous medications tried, their strengths, quantities, directions, dates, and reasons for discontinuation.
8. Provide any additional relevant medical rationale or clinical information that supports the request. Attach pertinent lab results and chart notes if available.
9. Lastly, ensure that the provider's signature and date are included at the end of the form to validate the submission.
10. After completing the form, save your changes, and choose to download, print, or share the form as needed to submit it to CareSource.

Begin filling out the CareSource Pharmacy Prior Authorization Request Form online today to ensure your medication needs are addressed promptly.