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SED/HYP.15 Form # 30110 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 09:23:36

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File Size: 32,00 KB

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MedicalCondition

Medical Necessity Documentation Insomnia / Full insomnia / /

Organization

Department of Health / /

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Product

Temazepam / Mirtazapine / Sonata / Triazolam / Doral / Estazolam / Ambien / Lunesta / Rozerem / Zolpidem / Zaleplon / /

ProvinceOrState

Pennsylvania / /

URL

www.mainecarepdl.org_ / /

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