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Get WI F-11078 2011

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11078 (10/11) STATE OF WISCONSIN DHS 107.10(2), Wis. Admin. Code FORWARDHEALTH PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR PROTON PUMP INHIBITOR (PPI) CAPSULES AND TABLETS Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets Completion Instructions, F-11078A. Providers may refer .

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