PRIOR AUTHORIZATION FORM - MaineCare PDL
Sep 23, 2020 · MaineCare/MEDEL Prior Authorization Form. ANTIBACTERIAL ANTIBIOTICS . Phone: 1-888-445-0497 www.mainecarepdl.org. Fax: 1-888-879-6938. Drug Name Strength Dosage Instructions Quantity Days Supply Circle Refills (34 retail / 90 mail order) ................
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