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PRIOR AUTHORIZATION FORM Sirturo Commercial/Medicaid Unless otherwise indicated below, authorization quantities are limited to the manufacturer recommended dosageComplete online at www.selecthealth.org/pa

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What is will sirturo be given?

Will Sirturo is a medication used to treat tuberculosis.

Who is required to file will sirturo be given?

Healthcare providers are required to prescribe Sirturo to eligible patients.

How to fill out will sirturo be given?

Sirturo should be taken orally with food.

What is the purpose of will sirturo be given?

The purpose of giving Sirturo is to treat tuberculosis infections.

What information must be reported on will sirturo be given?

Information such as patient name, dosage, frequency of administration, and any side effects should be reported when prescribing Sirturo.

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