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Effective Date: 
4/2020

Documents

 

Instructions

Update: 4/2020

 

Purpose

For prescribing providers to request pharmacy prior authorization (PA) for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.

When to Prepare

Detailed Instructions

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

Transmittal

  • Fax: 866-469-8590

Questions