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Prescription Drug Prior Authorization Request Form

Effective 1/1/2015, The State of California under SB 866  requires physicians to use this universal prescription form to submit prior authorization requests for prescription and injectable medications to the health plan, health insurer, or risk entity responsible for authorizing the medication.  Please complete this form when sending requests to Meritage for injectable meds which require authorization.  As this is a Universal  prescription form, it can be used to submit prior authorization medication requests to any health plan.

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