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Get UPMC Health Plan Prior Authorization Form 2012-2024

800-979-UPMC (8762) FAX 412-454-7722 PLEASE TYPE OR PRINT NEATLY Please complete all sections of this form AND include details of past relevant medical treatment, which substantiates the need for an exception to using formulary alternatives, i.e. past prescription treatment failures, documented side effects, chart documentation, lab values, etc. Incomplete responses may delay this request. Office Contact: Provider Specialty: Provider First Name: Provider Last Name: Provider Phone: Provide.

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