Sample Notes Page - CareFirst BlueCross BlueShield
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Prescription Drug Detail
Brand Name
Brand Tier
Generic Name
Generic Tier
PEGASYS
(Tier
2
)
Not
Available
Not
Available
Prior Authorization Required:
Yes
Quantity Limit:
No
Category:
Diseases\Hepatitis
Maintenance Drug:
No
Notes:
This medication requires Prior Authorization. Please have your physician call 1-866-522-2486 before prescribing this medication. Please use appropriate form if prescribing standard or triple therapy
Attachments:
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