Member Exception Request for Non-Formulary Medication

Fill out this form to ask for an exception for a non-formulary medication. This means you are asking us to cover a drug your plan does not cover now. The CareSource PASSE Pharmacy department will review within 24 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:

**For urgent requests: Call Member Services. The number can be found on the back of your Member ID card.

AR-PAS-M-3264120 DHS Approved: 12/12/2024