Member Exception Request for Non-Formulary Medication

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:

IN-MED-M-3264016 First use: 10/02/2024 OMPP Approved: 10/02/2024