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Prior Authorization Form Beta Blocker Step Therapy This form is based on Express Scripts standard criteria and may not be applicable to all patients certain plans and situations may require additional information beyond what is specifically requested. Fax completed form to 1-800-357-9577 Additional forms available www. express-scripts. com/pa If this an URGENT request please call 1-800-417-8164 Patient Information Prescriber Information Patient F.

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