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Confidential Page 1 of 2 Effective 1/1/2017 BASAGLAR TRESIBA condition based on published guidelines or clinical literature e.g. Toujeo If yes please 6. Caremark is an independent company that that administers prescription drug benefits on behalf of BlueChoice. Basal BASAGLAR TRESIBA PHYSICIAN PRIOR AUTHORIZATION REQUEST FORM BlueChoice HealthPlan Patient Information Name Insurance ID Number Address Birthdate Provider Information Physician s Name Physician DEA Number Phone Number Fax Number...
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