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Web if you have 10 or fewer drugs, please select the direct member reimbursement tab. Web prior authorization form navigator. Question 1 * answer 1. This file may not be suitable. Web attach any additional.

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Thank you for downloading the prior authorization. If you have more than 10 drugs or a compound drug, please use the dmr form(c) for. Prescriber visits proact’s promptpa portal, attaches. Service code if available (hcpcs/cpt) new prior authorization.

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Web attach any additional documentation that is important for the review (e.g., chart notes or lab data, to support the prior authorization). Information contained in this form is protected. A registered medical practitioner (for example the patient’s. This file may not be suitable.

Web If You Have 10 Or Fewer Drugs, Please Select The Direct Member Reimbursement Tab.

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