CareSource

Member Request for Medication Exemption

If you would like to submit a request for the review of a medication exemption by the CareSource Pharmacy department, fill in the information below and it will be evaluated 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:

Directions for Medication:

Reason for Exception:

** For urgent requests, call Member Services. The number can be found on the back of your CareSource member ID card.

NV-MED-M-4155977