Prior Approval Process (12 rows returned) List
| | | » | Prior Approval Process (12 rows returned) |
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| Pharmacy Prior Authorization Request Process Guide | PDF | 198.4 | 12/19/2023 | |
| Synagis Policy Statement RSV Season 2021-2022 (Revised 07.25.2022) | PDF | 212 | 07/25/2022 | |
| Synagis PA Request Form | PDF | 148.9 | 10/01/2021 | |
| Opioid MME Maximum PA Request Form | PDF | 89 | 09/06/2019 | |
| Emflaza Prior Authorization Request Form | PDF | 159.5 | 09/05/2018 | |
| HCV Re-Treatment PA Request Form | PDF | 47.1 | 09/05/2018 | |
| Non-Preferred Statin Request Form | PDF | 157.8 | 09/05/2018 | |
| Proton Pump Inhibitors PA Request Form | PDF | 106.9 | 09/05/2018 | |
| Tobacco Cessation PA Request Form | PDF | 124.5 | 09/05/2018 | |
| Multi-Ingredient Compound Drug PA Request Form | PDF | 115.8 | 10/31/2017 | |
| Nursing Facility Prior Authorization Issue Correction Steps | PDF | 422.8 | 02/16/2015 | |
| Non-Preferred Statin Request Form | PDF | 121.9 | 01/16/2013 | |