Specialty Pharmacy Prior Authorization Form
A standardized form and instructions for requesting prior authorization for specialty pharmacy or medical benefit drugs for CareSource members; used by prescribing and servicing providers to submit PA requests and required documentation.
No material clinical or coverage changes in this revision.
Coverage stance and procedure
Coverage stance and procedure
This form does not list drug-specific coverage criteria. Prior authorization determinations are made based on medical necessity, required documentation, and member eligibility; drug-specific clinical requirements are referenced in the corresponding pharmacy policy.
ALL of the following
- Request via the Specialty Pharmacy Prior Authorization Form (indicate Urgent or Standard) and submit to the appropriate fax number: Pharmacy Benefit fax 1-866-930-0019 or Medical Benefit fax 1-888-399-0271.
- Include clinical documentation and all required test results and medication history; prior authorization requests without medical justification or required test results will be considered INCOMPLETE and may be returned.
- Refer to the corresponding drug-specific pharmacy policy at CareSourcePASSE.com for clinical criteria and any drug-specific prior authorization requirements (this form does not list drug-specific criteria).
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