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Injectable Medication Precertification Request Injectable Medication Precertification Requ 2020
Member ID Group Medicare Yes No Medicaid Carrier Name C. Benlysta belimumab Injectable Medication Precertification Request Page 1 of 2 All fields must be completed and legible for Precertification Review. For ALL Requests clinical documentation required No Is this infusion request in an outpatient hospital setting No Has the patient experienced an adverse event with the requested product that has not responded to conventional interventions e.g. acetaminophen steroids diphenhydramine fluids...
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