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Pharmacy Prior Authorization Program Prior Authorization (PA) Cheat Sheet Forms Prior Authorization for Non-Preferred Drug Form PA01 - Modafinil PA02 - CNS Stimulants PA04 - Weight Loss PA05 - Follicle Stimulation PA06 - Growth Hormone PA09 - Botulinum Toxins PA10 - Agents Treating Pulmonary Hypertension PA11 - Fuzeon PA16 - Chronic Idiopathic Constipation PA17 - Qualaquin PA18 - Megace ES PA20 - Pradaxa PA21 - Xifaxan (550mg) PA22 - Treatment for Hepatitis C Sample Patient Contract for receiving treatment for Hepatitis C PA23 - Opioids PA24 - Yescarta_Kymriah PA24 - Yescarta_Kymriah Coverage Guidelines for Modified T-Cell Therapies General Pharmacy Prior Authorization Form