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Form Pca18560 - 17-Alpha-Hydroxyprogesterone Caproate (17-P) / Makena Prior Authorization Page 2

17-alpha-hydroxyprogesterone caproate (17-P) / Makena

Prior Authorization Form

Medication Information

Dose: _________________________________________________________

Medication:

Compounded 17-P (J2675)

Makena (J1725)

Directions: ______________________________________________________________________________________________________________

Quantity: _______________________________________________

Refills: ______________________

Duration of Treatment: ______________

Physician Signature: ______________________________________________________________________________________________________

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PCA18560

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