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NC Medicaid and NC Health Choice Pharmacy Prior Approval Request for PCSK9 Inhibitors Beneficiary Inform ation1. Beneficiary Last Name: ___ 2. First Name: ___ 3. Beneficiary ID #: ___ 4. Beneficiary
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Providers must report information such as the type of service provided, the date of service, the beneficiary's information, and any other relevant details required for reimbursement.
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