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Get Express Scripts Tricare Prior Authorization Form

Antilipidemic Drugs I - Prior Authorization Request Form MAIL ORDER and RETAIL To be completed and signed by the prescriber. To be used only for prescriptions which are to be filled through the Department of Defense DoD TRICARE Mail Order Pharmacy TMOP OR the TRICARE Retail Pharmacy Program TRRx. O. Box 52150 Phoenix AZ 85072-9954 or email the form only to TpharmPA express-scripts. com Prior authorization criteria and a copy .

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