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Formulary ExceptionPrior Authorization Request Form 2019
Brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. PLEASE COMPLETE CORRESPONDING SECTION FOR THESE SPECIFIC DRUGS/CLASSES LISTED BELOW AND CIRCLE THE APPROPRIATE ANSWER OR SUPPLY RESPONSE. ANTIFUNGALS No circle appropriate diagnosis If yes to question 1 is the onychomycosis confirmed by a fungal diagnostic test Yes or No ANTIOBESITY initial 4 percent weight loss Yes or No maintain their initial 5 percent...
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