Medical Necessity Criteria - Non-Covered Drugs Prior Authorization Form Page 2

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Fillable Medical Necessity Criteria - Non-Covered Drugs Prior Authorization Form Printable pdf

1

2

3

4

Reason for Failure:

[If yes, then no further questions.]

3.

Is this the only product the patient can use for their condition?

Y

N

I affirm that the information given on this form is true and accurate as of this date.

Prescriber (Or Authorized) Signature and Date

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