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Organic chemistry / Tretinoin / Acne vulgaris / Adapalene / Retinoid / Clindamycin / Benzoyl peroxide / Sulfacetamide / Rosacea / Anti-acne preparations / Chemistry / Medicine


Microsoft Word - Prior Authorization Request Form for Retinoid.doc
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Document Date: 2012-04-02 14:34:42

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File Size: 36,26 KB

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City

Cardholder / /

IndustryTerm

anti-acne products / /

MedicalCondition

Actinic Keratosis / Acne Vulgaris / Acne Rosacea / Acne / /

MedicalTreatment

antibiotics / /

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Product

erythromycin / Retin-A Micro / Topical / tretinoin / Azelex / Avita / doxycycline / Retin-A / Differin / Oral / /

ProvinceOrState

Florida / /

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