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Yes No Patient has had a trial of one preferred ophthalmic allergy product hydrochloride generic or NOTE Documentation must be provided for the trial of the preferred ophthalmic product. CONTAINS CONFIDENTIAL PATIENT INFORMATION besilate Prior Authorization of Benefits PAB Form Complete form in its entirety and fax to 1. Physician DEA Patient Email Address Physician NPI Patient ID Patient DOB Date of Rx 3. MEDICATION 4. Please refer to the applicable plan for the detailed information...
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