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Effective Date: 
4/2018

Documents

Instructions

Updated: 4/2018

 

Purpose

For prescribing providers to request pharmacy prior authorization for non-preferred phosphate binder agents.

When to Prepare

 

Detailed Instructions

  • Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax.

Transmittal

  • Fax: 866-469-8590

Questions