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Get NV FA-63 2017-2024

Ferred drugs in specific drug categories. Prior authorization is required for non-listed drugs within these categories. Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311. DATE OF REQUEST: RECIPIENT INFORMATION Last Name, First Name, Middle Initial: Date of Birth: Recipient ID: Gender: Male Female Phone: PRESCRIBING PROVIDER INFORMATION Name: NPI: Phone: Fax (required): Person to contact regarding this request: DIAGNOSIS AND REQUESTE.

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