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Provider Specialty: Provider First Name: Provider Last proventil Name: Patient UPMC Health Plan ID Generic equivalent drugs will be substituted for Brand name drugs unless you specifically indicate otherwise .
 New medication  Ongoing medication If ongoing, provide date If medication is ongoing, Did member Show improvement proventil while on therapy? Has the member tried Ventolin HFA? Please list all medications the member has previously tried or is currently using .
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proventil Proair HFA, Proventil HFA Prior Authorization Form IF THIS IS AN URGENT REQUEST, Please Call UPMC Health Plan Pharmacy Services .
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