REVIEW REQUEST FOR

Complete form in its entirety and fax to: Anthem Blue Cross 866-408-7195. Provider Data Collection Tool Based on Medical Policy DRUG.00013 & Clinical Guideline-DRUG-09. Policy Last Review Date: 05/15-2014 Policy Effective Date: 07/15/2014 Provider Tool Effective Date: 07/15/2014 Request Date: // Initial Request. Subsequent request. Buy and Bill ................
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