Form 1348, Phosphate Binders Standard PA Addendum (Medicaid)

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.
Effective Date
04/2018
Document
1348.pdf (110.98 KB)

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