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Fax completed prior authorization request form to 8773098077 or submit Electronic Prior Authorization through CoverMyMeds or Subscripts. All requested data must be provided. Incomplete forms or forms
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Individuals in Pennsylvania who are eligible for the CHIP program and are prescribed Corlanor medication may need the corlanor-request-form-pennsylvaniachip-6820 accessible pdf to request coverage for their medication.
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Corlanor-request-form-pennsylvaniachip-6820 accessible pdf is a form used to request coverage for the medication Corlanor under the Pennsylvania CHIP program.
Parents or legal guardians of children enrolled in the Pennsylvania CHIP program who are seeking coverage for Corlanor must file the form.
The form must be filled out completely and accurately, providing all required information about the child, their medical condition, and the necessity for Corlanor.
The purpose of the form is to request coverage for the medication Corlanor under the Pennsylvania CHIP program for eligible children.
The form requires information about the child's medical condition, previous treatments, and the prescribing physician's recommendation for the use of Corlanor.
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