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Member Exception Request for Non-Formulary Medication
If you would like to submit a request for the review of a non-formulary 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:
Medication Directions for Use:
Reason an Exception is Needed:
Multi-EXC-M-1814809
