UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM EMEND-(aprepitant) Patient name:___________________________________Medicaid ID - Chemotherapy regimens - Document - PDFSEARCH.IO

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	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM EMEND-(aprepitant) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Prescriber NP Add to Reading List Document Date: 2014-08-07 16:26:16 Open Document File Size: 20,21 KB Share Result on Facebook Facility Pharmacy Phone# / / MedicalCondition highly emetogenic cancer / acute and delayed nausea / vomiting / cancer / Patients receiving cancer / / MedicalTreatment chemotherapy / / Organization DEPARTMENT OF HEALTH / / Product Kytril / Requested Medication / Cisplatin / EMEND / Zofran / Aloxi / Anzemet / / Technology chemotherapy / / SocialTag Antiemetics Oncology Chemotherapy regimens Aprepitant Lactams Morpholines Dolasetron Chemotherapy Cisplatin Chemistry

UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM EMEND-(aprepitant) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Prescriber NPAdd to Reading List