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PRIOR AUTHORIZATION REQUEST FORM BM CHP 9.126 Systemic Immunomodulators 1 Enamel, Humor Version 21.0 Effective Date 11/14/17 Phone: 8885660008 Fax back to: 8667418136 Envisioned Options manages the

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What is 126 systemic immunomodulators?

126 systemic immunomodulators are substances that modify or regulate the immune system in the body.

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Healthcare providers or institutions using or prescribing 126 systemic immunomodulators are required to file.

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The purpose of 126 systemic immunomodulators is to regulate the immune system to treat various diseases and conditions.

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The information reported must include the name of the substance, dosage, frequency of use, and patient information.

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