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Autoimmune Checklist

Autoimmune Drug Details Include all IV, IM and oral medications in the regimen in one preauthorization. Refer to the physician orders. Attach a document with additional drugs, if necessary. Drug name Dose and units (e.g. 60 mg/m2) Route (e.g., IV, Oral) Administration Schedule HCPCS code Site of service (circle one): Inpatient Outpatient

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