Form F-11035 - Prior Authorization/preferred Drug List (Pa/pdl) For Cytokine Page 3

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PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR CYTOKINE AND CELL ADHESION
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MOLECULE (CAM) ANTAGONIST DRUGS FOR CROHN’S DISEASE
F-11305 (01/2016)
SECTION VI — ADDITIONAL INFORMATION
29. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the
product requested may be included here.
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