Get Caresource Pharmacy Prior Authorization Request Form 2020-2026

This guide provides clear instructions on how to successfully complete the CareSource Pharmacy Prior Authorization Request Form online. By following the steps outlined here, users can ensure that they provide all the necessary information for their request.

Follow the steps to complete the form correctly.

1. Click the ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by filling out the Patient Information section. Indicate whether the request is non-urgent or urgent, and provide the patient’s name, CareSource ID, date of birth, gender, medication allergies, and the details of the pharmacy including its name, phone number, and National Provider Identifier (NPI). You should also include the patient's height and weight.
3. Next, proceed to the Provider Information section. Complete the prescriber’s name, NPI number, specialty, address, office fax number, and phone number.
4. In the Medication Requested section, provide the Drug Name, strength, dosage directions (Sig), duration of therapy in days or months, and quantity needed. If applicable, include the HBA1C level with the date.
5. Indicate if the patient is currently being treated with the medication. If so, provide the date treatment started. Then, state the diagnosis.
6. For the Medical Justification section, include a detailed explanation of previous medications attempted along with their outcomes. This should include information for each previous medication tried, such as name, strength, quantity, directions, dates of use, and reasons for discontinuation.
7. Finally, include any relevant medical rationale for the request as well as additional clinical information. Attach any relevant lab results and chart notes as necessary.
8. Review all completed information to ensure accuracy and completeness. Finally, save your changes, and download, print, or share the completed form as needed.

Complete your CareSource Pharmacy Prior Authorization Request Form online today.