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Get SCAN Health Plan Tier Exception Form 2011-2024

Umber: Date of Birth: Prescriber s Name: Contact Person: Office phone: Office Fax: Requested Tier 4 Medication: Diagnosis: 1. Are there any drug-to-drug interactions with Tier 3 formulary alternative(s) and other medications that do not exist with the requested Tier 4 medication? 2. Would Tier 3 formulary alternative(s) have adverse effects that do not exist with the requested Tier 4 medication? 3. Are there any contraindications for the use of Tier 3 formulary alternative(s) that.

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Keywords relevant to SCAN Health Plan Tier Exception Form

  • applicable
  • diagnoses
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  • medications
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