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Medicine / HIV/AIDS / Hepatitis B / Viruses / Interferon / HBcAg / Viral load / Viral hepatitis / Nitazoxanide / Antivirals / Biology / Microbiology


Microsoft Word - Prior Authorization Request Form for Intron A.doc
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Document Date: 2012-04-02 14:08:36

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File Size: 43,13 KB

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City

Cardholder / /

Facility

Pharmacy Information Pharmacy Name / /

IndustryTerm

interferon product / /

MedicalCondition

genital warts / Follicular Non-Hodgkin’s Lymphoma Hairy Cell Leukemia Malignant Melanoma / depression / chronic hepatitis C / HBV / hepatitis B / HCV / /

MedicalTreatment

chemotherapy / /

/

Product

Infergen / Intron A / /

ProvinceOrState

Florida / /

Technology

chemotherapy / Genotype / /

SocialTag