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Get AL Form 369 2015

Y and alternative management choices Drug/therapy Reason for d/c Drug/therapy Reason for d/c r Antipsychotic Agents The request is for: r Monotherapy or r Polytherapy For children < 6 years of age, have monitoring protocols (see Attachment C on the Alabama Medicaid website) been followed? r Yes r No For polytherapy and/or off-label use, please provide medical justification to support the use of the drug being requested. Medical justification may include peer reviewed literature, medi.

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