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Gateway prior auth form

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The document is a Non-Formulary Drug Exception Form used to request prior authorization for specific medications not included in the formulary. It requires member and pharmacy information, clinical details about the requested drug, documentation of previous formulary alternatives tried, and prescriber information. The form must be faxed to a designated number, and if denied, prescribers can either switch to a formulary alternative or appeal the decision.

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Versions	Form popularity	Fillable & printable
2011	4 Satisfied (32 Votes)

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