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Get Blue Advantage BCBS Medicare Part D Prescription Drug Authorization Request Form 2015-2024

( please check one) Prior Authorization Step Therapy Exception Request Non-formulary Drug Request for Quantity Limit Exception Appeal Patient Name STANDARD REQUEST EXPEDITED REQUEST Request for Tiering Exception Date of Birth (mm/dd/yyyy) Patient s Home Address Contract Number (Include Prefix) City Patient Phone Number State Zip PHYSICIAN INFORMATION Physician Name Practice Type: Practice Address PCP Specialist Physician UPIN City State Office Phone Office Fax.

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