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01/04/2016 Prior Authorization MERCY MARICOPA INTEGRATED CARE - TXIX/XXI SMI MEDICAID Step Therapy AZ88 This fax machine is located in a secure location as required by HIPAA regulations. Face or eyelids AND had a trial and failure or intolerance to at least 2 different formulary topical corticosteroids Please list topical steroids tried of 1 formulary low-potency topical corticosteroid i.e. hydrocortisone aclometasone area Comments I affirm that the information given on this form is true and...
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