Fillable medco health medicare part d prior auth form

Description
35045 *35045* Medicare Part D Prior Authorization Request Form (page 1 of 2) Please complete both pages and return to Medco by fax at 1-800-837-0959. Please indicate if you are requesting urgent processing Yes If yes, state rationale for urgent processing: If you have any questions, you may contact us toll-free at 1-800-753-2851. PATIENT INFORMATION First and Last Name:
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medco health medicare part d prior auth
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