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Office of Medical Assistance Programs FeeforService, Pharmacy Division Phone 18005378862 Fax 18663270191ORENCIA () nonpreferred PRIOR AUTHORIZATION FORM Cytokine and CAM Antagonists and Quantity Limits/Daily
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What is non-preferred prior authorization form?
Non-preferred prior authorization form is a documentation used to request approval from an insurance company for a medication or treatment that is not on the preferred drug list.
Who is required to file non-preferred prior authorization form?
Patients or healthcare providers are required to file a non-preferred prior authorization form when requesting coverage for a non-preferred medication or treatment.
How to fill out non-preferred prior authorization form?
To fill out a non-preferred prior authorization form, you will need to provide information about the patient, the medication or treatment being requested, and the medical necessity for the non-preferred option.
What is the purpose of non-preferred prior authorization form?
The purpose of a non-preferred prior authorization form is to ensure that the requested non-preferred medication or treatment is medically necessary and meets the insurance company's criteria for coverage.
What information must be reported on non-preferred prior authorization form?
The non-preferred prior authorization form must include the patient's personal information, details about the healthcare provider, the specific medication or treatment being requested, and the medical justification for choosing the non-preferred option.
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