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ACE/ARB ARB/CCB RENIN INHIBITOR PREAUTHORIZATION REQUEST PHYSICIAN FAX FORM ONLY the prescriber may complete and fax this form. Incomplete forms will be returned for additional information. The following documentation is required for preauthorization consideration. For formulary information and to download additional forms please visit www. Patient has tried brand-name products generic products or over-the-counter products. Please fax or mail this form to Blue Cross and Blue Shield of Texas...
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