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TEXAS MEDICAID Preferred Drug List (PDL) Criteria for Non

WEBRev. 10/26/2020 Page 1 of 1 Version 1.0 STEP 1: CLEARLY PRINT AND COMPLETE TO EXPEDITE PROCESSING Date: Prescriber First & Last Name: Patient First & Last …

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URL: https://txstarchip.navitus.com/misc-pages/pdf-form-viewer.aspx?FormID=35b12d44-cda5-4298-b1f6-fda0e5ed55cc

Texas Medicaid Providers

WEBwelcome Texas Medicaid Providers. We work closely with you to support your Texas Medicaid STAR, CHIP, and STAR Kids patients

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Texas Medicaid – Texas Children’s Health Plan Respiratory …

WEBThe pharmacy faxes both the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits and the completed form to the NAVITUS Prior Authorization …

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Synagis (palivizumab)

WEBTexas Prior Authorization Program Clinical Criteria Synagis (Palivizumab) October 4, 2019 Copyright © 2011-2019 Health Information Designs, LLC 4

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Texas – DELL CHILDREN’S HEALTH PLAN Clinical Edit Prior …

WEBTitle: Microsoft Word - Contraceptives_ Dell Children's Health Plan_TX_120916 Author: atw1007a Created Date: 12/9/2016 8:48:44 AM

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TEXAS MEDICAID Clinical Edit Prior Authorization Phosphate …

WEBRev. 07/29/2022 Page 3 of 3 Version 1.6 TEXAS MEDICAID Clinical Edit Prior Authorization Phosphate Binders 10. Does the client have a history of dialysis with …

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TX PA Recorlev Clin Edit Criteriav1

WEBTexas Prior Authorization Program Clinical Criteria Recorlev (Levoketoconazole) April 22, 2022 Copyright © 2011-2022 Health Information Designs, LLC 7

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