Long Acting Narcotics Prior Authorization (PA) Request Form
Prior Authorization (PA) Request Form ... Magellan Rx Management, a division of Magellan Health, Inc. Member Information Member’s Last Name: Member’s First Name: Member’s ID Number: Date of Birth (MM/DD/YYYY): – – ... b.If the member has NOT had an electrocardiogram (EKG) with normal QTc within 30 days prior to initiation ................
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