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Get and Sign Opioid Prior Authorization Form Maryland Medicaid 2019-2022

Result Diagnosis Criteria Repeat DAA Therapy Questions HCV treatment status Na ve Experienced Prior treatment regimen s Assessment of liver disease severity No cirrhosis Compensated cirrhosis Child Pugh A Decompensated cirrhosis Child Pugh B or C 4. milligram equivalent MME is over 90 MME per day c. Opioid s is/are prescribed concurrently with benzodiazepines If yes prescriber attests that a naloxone prescription and associated counseling on its use was or will be given to the patient d....

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