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MEDICARE FORM Viscosupplementation Injectable Medication Precertification Request Page 2 of 2 (All fields must be completed and legible for precertification review.) For Medicare Advantage Part B: PHONE: 1-866-503-0857 FAX: 1-844-268-7263 For other lines of business: Please use other form. Note: Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc,
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