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New Prior Authorization
Direct Member Reimbursement
Check Status
1
START
2
PATIENT
3
DRUG
4
PRESCRIBER
5
DIAGNOSIS
6
PROVIDER
7
FINISH
Please answer the following questions about this request...
Are you the...
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Patient / Member
Beneficiary’s Representative/AOR
*
*
Is this request for a...
Prescription Drugs
*
*
Where is the drug being obtained?
Retail Pharmacy
Mail Service Pharmacy
Specialty Pharmacy
*
*
(* Required Fields)
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PromptPA
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Please enter fax number and click "Verify" button to proceed.
Fax #1:
*
Reenter Fax #1:
*
Fax Secure:
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Yes
No
*
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