UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM Sodium-Glucose Co-transporter 2 (SGLT-2) Inhibitors (canagliflozin, dapagliflozin)) Patient name:_____________________________________Medicaid ID - Canagliflozin - Document - PDFSEARCH.IO

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	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM Sodium-Glucose Co-transporter 2 (SGLT-2) Inhibitors (canagliflozin, dapagliflozin)) Patient name:_____________________________________Medicaid ID #:__________ Add to Reading List Document Date: 2014-08-07 16:26:15 Open Document File Size: 88,00 KB Share Result on Facebook Facility Pharmacy Phone# / MedicalCondition diabetes mellitus / bladder cancer / / Organization DEPARTMENT OF HEALTH / / / Position pharmacist / / Product Requested Medication / / SocialTag Pharmacology Anti-diabetic drugs Eli Lilly and Company Pharmacist Metformin Insulin Dapagliflozin Pharmaceutical drug Sulfonylurea Medicine

UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM Sodium-Glucose Co-transporter 2 (SGLT-2) Inhibitors (canagliflozin, dapagliflozin)) Patient name:_____________________________________Medicaid ID #:__________Add to Reading List