Erectile Dysfunction Prior Authorization Request Form ...
Does the member have a history of failure, contraindication, or intolerance to tadalafil (generic Cialis)**? Yes No For brand Levitra requests, answer the following: Does the member have a history of failure, contraindication, or intolerance to vardenafil (generic Levitra)**? Yes No For brand Viagra requests, answer the following: Does the member have a history of failure, contraindication, or ... ................
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