Form Pca18558 - Enzyme Replacement Therapy For Gaucher Disease Prior Authorization Form Page 2

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Enzyme Replacement Therapy for Gaucher Disease
Prior Authorization Form
Medication
Dose
Directions
Refills
Preferred Product(s) – Prior Authorization NOT Required
VPRIV
(J3385)
®
Non-Preferred Product(s) – Prior Authorization Required; Prescriber must provide rationale
Elelyso
(J3060)
®
Cerezyme
(J1786)
®
Physician Signature
IMPORTANT NOTICE: This electronic fax transmission, including any attachments contains information that may be confidential and/or privileged. The information contained
in this facsimile is intended to be for the sole use of the individual(s) or entity named above. If you are not the intended recipient, be aware that any disclosure, copying,
distribution or use of the contents of this information is strictly prohibited by law and will be vigorously prosecuted. If you have received this electronic fax transmission in error,
please notify the sender immediately and destroy all electronic hard copies of the communications including attachments.
PCA18558
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