CareSource

Member Exception Request for Non-Preferred Medication

If you would like to submit a request for the review of a non-preferred medication by the CareSource Pharmacy department, fill in the information below and it will be evaluated within 72 hours.

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:

OH-MMED-0660a