Rebyota PA Forms - Medicare, Medicaid, Commercial Pharmacy (2025)

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Rebyota
Prior Authorization Forms

Farxiga vs. Glyxambi Berinert vs. Cinryze Emgality vs. Qulipta Farxiga vs. Invokana Firazyr vs. Sajazir Glyxambi vs. Invokana Invokamet vs. Synjardy Opzelura vs. Dupixent Orencia vs. Rinvoq Qulipta vs. Vyepti Stelara vs. Tremfya Synjardy vs. Victoza Taltz vs. Bimzelx Vyepti vs. Nurtec ODT View all Comparisons

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Beta-Adrenergic Blocker Angiotensin Converting Enzyme Inhibitor Angiotensin 2 Receptor Blocker Calcium Channel Blocker Diuretics HMG-CoA Reductase Inhibitor Proton Pump Inhibitor Selective Serotonin Reuptake Inhibitor Norepinephrine Reuptake Inhibitor Benzodiazepines Opioid Agonists Nonsteroidal Anti-inflammatory Drugs Antiepileptic Agents Antipsychotics Antihistamines View all Classes

Wegovy®Ozempic®Mounjaro®Zepbound®Jardiance®Farxiga®Dupixent®Trulicity®Lyrica®Lipitor®Effexor®Concerta®Depakote®Trintellix®Rexulti®Rinvoq®Verzenio®Taltz®

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