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Get Advantra Silver Prior Auth Form

N: DEA # Office Phone # Office Fax # Office Address: Tax ID Number: MEDICATION INFORMATION 1. Drug Requested: (Please include: dose/frequency/length of therapy.) 2. If Injectable medication, where is it being administered? Home (self-administered) Office administered 3. Diagnosis: (Please include all office notes supporting diagnosis.) 4. All covered Part D drugs on any tier of the Plan s formulary would not be as effective for the enrollee as the requested formulary drug an.

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