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Prior Approval Process

This section contains documentation related the Prior Approval Process.

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Prior Approval Process (12 rows returned) List

Prior Approval Process (12 rows returned)

 TitleFile TypeSize (KB)Release Date 
Pharmacy Prior Authorization Request Process GuidePDF198.412/19/2023 
Synagis Policy Statement RSV Season 2021-2022 (Revised 07.25.2022)PDF21207/25/2022 
Synagis PA Request FormPDF148.910/01/2021 
Opioid MME Maximum PA Request FormPDF8909/06/2019 
Emflaza Prior Authorization Request FormPDF159.509/05/2018 
HCV Re-Treatment PA Request FormPDF47.109/05/2018 
Non-Preferred Statin Request FormPDF157.809/05/2018 
Proton Pump Inhibitors PA Request Form PDF106.909/05/2018 
Tobacco Cessation PA Request FormPDF124.509/05/2018 
Multi-Ingredient Compound Drug PA Request FormPDF115.810/31/2017 
Nursing Facility Prior Authorization Issue Correction StepsPDF422.802/16/2015 
Non-Preferred Statin Request FormPDF121.901/16/2013 
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