PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) …
PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR PROTON PUMP INHIBITOR (PPI) CAPSULES AND TABLETS. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets Completion Instructions, F-11078A. ................
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