Fax Number: (800) 268-2990 New York State Medicaid Preferred Drug Program Zepatier™ Prior Authorization Worksheet Enrollee Information (2 5 1 OF Female Male Prescriber Information ( ) - ( ) - WITH AND TREATMENT C (HCV) TREATMENT 10 HCV 12 10 CME 12 Clinical Criteria MEDICAL STATUS
New York State Medicaid Preferred Drug Program Fax Number: (800) 268-2990 Zepatier™ Prior Authorization Worksheet Enrollee Information (2 5 1 Female Male Prescriber Information ( ) - ( ) - (HCV) AND 10 HCV 12 10 CME 12 Clinical Criteria MEDICAL STATUS C TREATMENT OF TREATMENT WITH
NYRx_PDP_PA_Worksheet_Prescribers_Zepatier.docx