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Get MA Standard Form for Medication Prior Authorization Requests 2016-2024

Quest ☐ Continuation/Renewal Request Reason for request (check all that apply): ☐ Prior Authorization, Step Therapy, Formulary Exception ☐ Quantity Exception ☐ Specialty Drug ☐ Other (please specify):                           Check if Expedited Review/Urgent Request: ☐ (In checking this box, I attest to the fact that this request meets the definition and criteria for expedited review and is an urgent request.) A.  Destination .

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