Get healthsmart rx prior authorization form

WV Public Employees Insurance Agency Pharmacy Prior Approval Program PO Box 9511 HSCN WVU School of Pharmacy Morgantown WV 26505 Phone 1-800-847-3859 FAX 1-800-531-7787 Prior Approval Request Form I. Patient and Medication Information Patient Name Last First MI Patient s PEIA Identification Dose Requested Medication Name Patient s Date of Birth Directions Primary Diagnosis for use of this drug Optional Diagnosis Code ICD-9-CM Secondary Diagnoses .

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