CareSource Pharmacy Prior Authorization Request Form 2013 free printable template

P.O. Box 8738 Dayton, OH 454018738 Pharmacy Prior Authorization Request Form Pharmacy Fax # 8669300019 Note: Prior Authorization Requests without medical justification or previous medications listed

How to fill out CareSource Pharmacy Prior Authorization Request Form

How to fill out CareSource Pharmacy Prior Authorization Request Form

1. Obtain the CareSource Pharmacy Prior Authorization Request Form from the CareSource website or your pharmacy.
2. Fill in the patient's information, including name, date of birth, and member ID.
3. Provide the prescribing physician's details, such as name and contact information.
4. Indicate the medication name, dosage, and frequency the physician is prescribing.
5. Include a diagnosis and any relevant medical history that supports the need for the medication.
6. Attach any additional documentation that may be required, such as clinical notes or test results.
7. Review the completed form for accuracy and completeness.
8. Submit the form via fax, mail, or as instructed by CareSource.

Who needs CareSource Pharmacy Prior Authorization Request Form?

1. Members of CareSource who are prescribed medications that require prior authorization.
2. Healthcare providers submitting prescriptions for medications that necessitate prior approval.

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What is CareSource Pharmacy Prior Authorization Request Form?

The CareSource Pharmacy Prior Authorization Request Form is a document used to request approval from CareSource for specific medication coverage before the medication can be dispensed to the patient. It ensures that the prescribed medication is medically necessary and meets the criteria for coverage.

Who is required to file CareSource Pharmacy Prior Authorization Request Form?

The CareSource Pharmacy Prior Authorization Request Form must be filed by healthcare providers, such as physicians or pharmacists, who prescribe medications that require prior authorization for their patients.

How to fill out CareSource Pharmacy Prior Authorization Request Form?

To fill out the CareSource Pharmacy Prior Authorization Request Form, providers should enter the patient's information, the prescribing provider's details, the medication name, dosage, and the reason for the prior authorization request. Necessary medical documentation should also be attached to support the request.

What is the purpose of CareSource Pharmacy Prior Authorization Request Form?

The purpose of the CareSource Pharmacy Prior Authorization Request Form is to evaluate the medical necessity of prescribed medications and to authorize coverage for those medications under the patient's insurance plan, ensuring appropriate use of healthcare resources.

What information must be reported on CareSource Pharmacy Prior Authorization Request Form?

The CareSource Pharmacy Prior Authorization Request Form must report information such as the patient's name and identification number, the medication requested, prescribing provider's information, diagnosis, medical necessity rationale, and any relevant clinical history or supporting documentation.