Passport Health Plan Prior Authorization Physician Chemotherapy Drug Request Form Note: Form must be completed in full. An incomplete form may be returned. Information on this form is protected health information and sub - Prior authorization - Document - PDFSEARCH.IO

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	Passport Health Plan Prior Authorization Physician Chemotherapy Drug Request Form Note: Form must be completed in full. An incomplete form may be returned. Information on this form is protected health information and sub Add to Reading List Document Date: 2014-03-31 16:22:43 Open Document File Size: 144,24 KB Share Result on Facebook City Glen Allen / / Company Magellan Pharmacy Solutions / / Facility Pharmacy NAME / / / MedicalTreatment Chemotherapy / / / Position Physician / Authorization Physician / / Product Carboplatin / Cisplatin / Ifosfamide / Prochlorperazine / Etoposide / Ranitidine / Dexamethasone / Cimetidine / Fluorouracil / Thiotepa / Paclitaxel / Amifostine / Mitoxantrone / Cytarabine / Mitomycin / Dacarbazine / Metoclopramide / Cyclophosphamide / Ondansetron / / ProvinceOrState Virginia / / Technology Chemotherapy / / SocialTag Eli Lilly and Company Ketones Methadone Organic chemistry Radioactivity Chemistry Amines Drug rehabilitation

Passport Health Plan Prior Authorization Physician Chemotherapy Drug Request Form Note: Form must be completed in full. An incomplete form may be returned. Information on this form is protected health information and subAdd to Reading List