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Please describe contraindication if applicable 2 of the following formulary anti-TNF s or or Please describe contraindication if applicable 8. 10/07/2015 Prior Authorization MERCY MARICOPA INTEGRATED CARE - TXIX/XXI SMI MEDICAID Xeljanz AZ88 This fax machine is located in a secure location as required by HIPAA regulations. AND at least 1 other oral DMARD or in combination or each as monotherapy If yes skip to question 6. Complete/review information sign and date. Fax signed forms to Mercy...
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