CareSource

External Review of a Drug Exception Request by Independent Review Entity

If we deny your request for an exception to a formulary drug in an Internal Review, you may complete this form to ask for an External Review of our decision. The external review will be assigned to an Independent Reviewer contracted by us to review the denial.

First Name:

Last Name:

Date of Birth:

CareSource Member ID:

Doctor's First Name:

Doctor's Last Name:

Doctor's Phone Number

Doctor's Fax Number

Medication Name:

Medication Strength:

Directions for Medication:

Reason for Exception:

Multi-EXC-M-2640485