Passport Health Plan Prior Authorization Zoladex® or Lupron® Note: Form must be completed in full. An incomplete form may be returned. Information on this form is protected health information and subject to all privacy - Prior authorization - Document - PDFSEARCH.IO

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	Passport Health Plan Prior Authorization Zoladex® or Lupron® Note: Form must be completed in full. An incomplete form may be returned. Information on this form is protected health information and subject to all privacy Add to Reading List Document Date: 2014-03-31 16:36:38 Open Document File Size: 232,78 KB Share Result on Facebook City Glen Allen / / Company Magellan Pharmacy Solutions / / Facility Local Pharmacy / / / MedicalCondition dysfunctional uterine bleeding / R/O tumors / Fibroids / menorrhagia / anemia / uterine fibroids / Provide Information Accordingly Advanced Prostatic Cancer Advanced Breast Cancer Endometriosis / Central Precocious Puberty / osteoporosis / / MedicalTreatment hormone replacement therapy / oral contraceptives / / Organization OF SERVICE / / Person Uterine Leiomyomata / / / Position Physician / / Product Fosamax / Vitamin D / norethindrone acetate / Zoladex / Lupron / / ProvinceOrState Virginia / / SocialTag Menstrual cycle Leuprorelin Menorrhagia Breast cancer Uterine fibroid Leiomyoma Health Insurance Portability and Accountability Act Hormone replacement therapy Cancer Medicine

Passport Health Plan Prior Authorization Zoladex® or Lupron® Note: Form must be completed in full. An incomplete form may be returned. Information on this form is protected health information and subject to all privacyAdd to Reading List