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Aetna - Medical Exception/Prior Authorization ...

New Therapy . Renewal . If Renewal, Date therapy initiated: Route of administration: Oral/SL . Topical . Injection . IV . Other: Administered: Doctor’s Office . Dialysis Center. Home Health . By Patient . Other: Medication Name Dose/Strength . Frequency Length of Therapy Number of Refills Quantity ; List of Previous Drugs Tried Drug Name; Dosage

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  Aetna, Medication, Authorization, Therapy, Prior, Prior authorization

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