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Host name	172.67.175.84
IP address	172.67.175.84
Location	United States
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Longitude	-97.822
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Prior Authorization Form Fax completed form to 1-877-251-5896

08.22.2011 . This form is basedon Express Scripts standardcriteria and may not be applicableto all patients; certain plansand situations may require

Collegiumcoverage.com

DA: 21 PA: 50 MOZ Rank: 84

Belbuca® Prior Authorization Request Form (Page 1 of 2)

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI).

Collegiumcoverage.com

DA: 21 PA: 46 MOZ Rank: 68

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