Form 1346, Makena Standard PA Addendum (Fee for Service Medicaid)

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Effective Date
06/2019
Document
1346.pdf (114.14 KB)

 

Instructions

Updated: 3/2018

 

Purpose

For prescribing providers to request pharmacy prior authorization for Makena.

When to Prepare

 

Detailed Instructions

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

Transmittal

  • Fax: 1-866-469-8590

Questions