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Managed Care Referral Fax Form - Opens in a new window
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MN Uniform Form for Medical Drug PA Request and Formulary Exceptions - Opens in a new window
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Rule 5 County Screening Referral Form - Opens in a new window
Program effective Date: Oct 31, 2024
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Formulary Exception and Tier Authorization - Only SecureBlue (HMO) (PDF) - Opens in a new window
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Inpatient Admission Notification and Prior Authorization Request Form (PDF) - Opens in a new window