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Get Wellcare Authorization Form

By a physician with a Drug Addiction Treatment Act (DATA) waiver** (UIN #) Drug Requested: SL Film Tab 8mg/2mg SL Film Tab 2mg/0.5mg SL Tab 8mg SL Tab 2mg Quantity: Sig: Start date of this PA: **Doses above 32mg per day will NOT be approved. 1. Primary Diagnosis: ICD-9: 2. Psychosocial Counseling (submit no.

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