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It must be legible correct and complete or form will be returned. Pharmacy NPI Pharmacy fax NDC Prior authorization is required for teriflunomide Aubagio or dimethyl fumarate . The required trial may be overridden when documented evidence is provided that the use of these agents would be medically contraindicated. Preferred Aubagio Strength Dosage Instructions Quantity Days Supply Diagnosis Treatment failure with or non- Trial Drug Name Dose Trial Dates Reason for failure Possible drug...

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What is aubagio - iowamedicaidpdlcom?

Aubagio - iowamedicaidpdlcom is a form used to request coverage for the medication Aubagio through the Iowa Medicaid program.

Who is required to file aubagio - iowamedicaidpdlcom?

Patients who are seeking coverage for Aubagio through the Iowa Medicaid program are required to file aubagio - iowamedicaidpdlcom.

How to fill out aubagio - iowamedicaidpdlcom?

Aubagio - iowamedicaidpdlcom can be filled out by providing all the necessary information about the patient, healthcare provider, and the medication Aubagio.

What is the purpose of aubagio - iowamedicaidpdlcom?

The purpose of aubagio - iowamedicaidpdlcom is to request coverage for the medication Aubagio under the Iowa Medicaid program.

What information must be reported on aubagio - iowamedicaidpdlcom?

Information such as patient's demographics, healthcare provider information, diagnosis, treatment plan, and medication details must be reported on aubagio - iowamedicaidpdlcom.

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