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UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM ALOXI (palonostron hcl) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Prescrib
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Document Date: 2014-08-07 16:26:15
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File Size: 10,40 KB
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Facility
Pharmacy Phone# /
/
MedicalCondition
vomiting /
moderately emetogenic cancer /
delayed nausea /
/
MedicalTreatment
chemotherapy /
/
Organization
DEPARTMENT OF HEALTH /
/
Product
Kytril /
Requested Medication /
Zofran /
ALOXI /
Anzemet /
/
Technology
chemotherapy /
/
SocialTag
Antiemetics
Ketones
Oncology
Lactams
Dolasetron
Indoles
Granisetron
Palonosetron
Ondansetron
Medicine
UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM ALOXI (palonostron hcl) Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Prescrib