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Organic chemistry / Stimulants / Technology / Benzazepines / Pyrazines / Varenicline / Nicotine / Fax / Nicotinic agonists / Chemistry / Smoking cessation


UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM Chantix (varenicline) Patient name:_______________________________Medicaid ID #:________________________________ Prescriber Name:________________Prescriber NPI#
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Document Date: 2014-08-07 16:26:15

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Facility

Pharmacy Phone# /

MedicalCondition

nicotine dependence / /

Organization

DEPARTMENT OF HEALTH / /

/

Product

Requested Medication / nicotine / Chantix / /

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