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Get form 1728

Ecialty Medication where there is no drug specific form. For non-specialty medication, please use US Script Prior Authorization form. Drug Name (include strength and dosage) Dates of Therapy Reason for Discontinuation 1. 2. 3. 4. NOTE: confirmation of use will be made from member history on file; prior use of preferred drugs is part of the exception criteria 5. Please state Rationale for Request / Pertinent Clinical Information (Required for all prior authorizations) Physician s Signature.

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