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Get and Sign AmeriHealth Caritas Pennsylvania PerformRx Prior Authorization Form Universal Pharmacy Oral Prior Authorization Form 2014
Sample logs Rationale and/or additional information which may be relevant to the review of this prior authorization request Physician Signature Date Please return this form to FAX to 1-888-981-5202 PerformRx AmeriHealth Caritas Pennsylvania 200 Stevens Drive Philadelphia PA 19113 Revised 11/2014 Injectable Requests - Please call 1-866-610-2774 Made Fillable by eForms....
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