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ANTFG.21 Form # 10120 R:4.14 State of Maine Department of Health & Human Services MaineCare/MEDEL Prior Authorization Form
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Document Date: 2014-04-21 09:09:59

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File Size: 38,00 KB

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MedicalCondition

vascular disease MUST / infection / pain / weeks Symptomatic onychomycosis / /

MedicalTreatment

Immunosuppression / /

Organization

Department of Health / /

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Product

LAMISIL / Triamcinolone / NOXAFIL / Clotrimazole / Nystatin / FLUCONAZOLE / SPORANOX / ITRACONAZOLE / PENLAC / /

URL

www.mainecarepdl.org_ / /

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