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Get and Sign Moda Health Prior Authorization Form
Necessity:
***PLEASE RESPOND TO ALL QUESTIONS ON THE FOLLOWING PAGE(S)***
INTERNAL USE ONLY
Date received:
Date of review:
Reason for Clinical Review:
PAC:
Does not meet criteria
DAW Difference Exception
Drug not in Formulary
Step Therapy not met
High Dollar (________________)
Over QLL
Other:
(______per______DS)
Approved for: ______________
Denied
Approved for one year
Approved for length of benefit
Reason:
Clinician Signature: ___________________________________
DATE:...
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