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>> /S /S /Off 102 0 R /Ff 8388608 >> pharmacy program does not cover all medications. /P 91 0 R /Tabs /S >> /N << >> endobj endobj ?-e� �( /Length 22 >> /N << >> endstream /N << /P 91 0 R /A4 331 0 R /Type /Annot The opioid crisis in the United States has come about because of excessive use of these drugs for both legal and illicit purposes and unprecedented levels of consequent opioid use disorder (OUD). If you run into any issues, ask the pharmacy to contact the health plan. /Type /StructTreeRoot /66 [5413.0 62.0 4.0 -154.08 168.8 0.0 179.68 1.0 0.0 0.0 >> endobj /P 91 0 R /Subtype /Form >> /BBox [0.0 6.2 6.2 0.0] /Filter /FlateDecode >> /NumberOfPageItemsInPage 4 This information is intended only . << /Rect [42.48 592.76 48.68 598.96] /T <2A436F6E7461637420617420536572766963696E672050726F76696465729073204F66666963653A2034> 2021-08-30T15:27:40-04:00 endobj endstream >> /0 [229.0 0.0 2.0 -275.04 -351.0 270.0 -321.14 1.0 0.0 0.0 >> /Matrix [1.0 0.0 0.0 1.0 0.0 0.0] /T1_1 304 0 R /H /P stream
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1.0 302.312 469.392] Medication Prior Authorization Requests Form. /BS << /CS0 [/ICCBased 301 0 R] /BG [] >> /Filter /FlateDecode /ColorSpace << /Parent 4 0 R • Request an emergency prescription be filled for 72 hours for a drug requiring prior authorization if a prior authorization cannot be obtained outside of health plan business hours. /V /Off >> << /34 [5241.0 30.0 4.0 161.94 -224.96 168.14 -218.76 1.0 0.0 0.0 >> << /Subtype /Form /AS /Off Requested CPT code (s) (Click + or - at the right to add up to 5 CPT Codes) Example CPT code: 12345. /T (Non-participating 4) /W 1 >> /27 [4298.0 26.0 4.0 87.28 -306.084 143.44 -282.457 0.210815 0.0 0.0 /ColorSpace << We are committed to providing appropriate, high-quality, and cost-effective drug therapy to all New Hampshire Ambetter members. /Info 343 0 R >> Has the patient been seen by any specialist who has recommended Synagis ®? >> 105 0 obj << /Subtype /Form 124 0 obj endstream /Yes 133 0 R /F 4 126 0 obj /Matrix [1.0 0.0 0.0 1.0 0.0 0.0] /Off 174 0 R /BBox [0.0 6.2 6.2 0.0] /StructParents 6 >> /W 1 >> /Filter /FlateDecode /W 1 /N << 14 0 obj /BS << /0 1773 /W 1 /Subtype /Form /Rect [42.48 519.76 48.68 525.96] /StructParent 34 /ColorSpace << ?-e� �( /BleedBox [0.0 0.0 612.0 792.0] /FT /Btn /Matrix [1.0 0.0 0.0 1.0 0.0 0.0] /F 4 /Resources << 81 0 obj /0 [2064.0 0.0 4.0 -270.0 -343.63 270.0 -343.13 1.0 0.0 0.0 endstream /ExtGState << stream
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