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Get NM EviCore Healthcare Drug Prior Authorization Request Form

The state of New Mexico requires the use of this form for pharmacy prior authorization requests and UnitedHealthcare is posting it on their behalf for our providers. Fax form to: 8005402406.(6)* Patient.

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  8. Click Done in the top right corne to save and send or download the document. There are several options for receiving the doc. An attachment in an email or through the mail as a hard copy, as an instant download.

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