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Get Cigna Uniform Pharmacy Prior Authorization Request Form 2020-2024

Y 1, 2020, no prior authorization requirements may be imposed by a carrier for any FDA-approved prescription medications on its formulary which is approved to treat substance use disorders. Urgent 1 Non-Urgent Requested Drug Name: Is this drug intended to treat opioid dependence? Yes No Yes* No* If Yes, is this a first request within a 12 month period for prior authorization for this drug? * If Yes, prior authorization is not required for a 5-day supply of any FDAapproved drug for the tr.

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