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Get Exception To Coverage Request - Dean Health Plan

REQUIRED CRITERIA AND FAX TO: NAVITUS HEALTH SOLUTIONS 920-735-5350 Date: Prescriber Name: Patient Name: Prescriber NPI: Unique ID: Prescriber Phone: Date of Birth: Prescriber Fax: REQUEST TYPE: 1 2 3 4 5 Quantity Limit Increase1 Gender-Specific2 New Drug4 High Dose3 Not Covered5 Quantity Limit Increase: Dose prescribed exceeds allowed quantity limits. Indicate diagnosis/clinical rationale why the covered quantity and/or dosing are insufficient. See formularies at navitus.com.

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