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Get MD Tier 2 and Non-Preferred Antipsychotic Prior Authorization Form 2012

Yprexa Relprevv other: _________ Dosage Form: ________________Strength: ______________ Frequency: __________________Quantity: __________ Dosage Form: ________________ Strength: _________ ______Frequency: __________________Quantity: __________ Is requested medication a continuation of therapy from an inpatient setting? Yes Does the patient have a condition that prevents the use of the preferred medication? No Yes No If yes, please specify: ____________________________________________________.

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