Hmo Part B Drug Prior Authorization Request Form Page 3

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Prescriber signature_________________________________________________Date________________________
Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.
15-071_H6453
18NW2246 11/15
Blue Advantage from HMO Louisiana, Inc. is an HMO plan with a Medicare contract. HMO Louisiana is a subsidiary of
Blue Cross and Blue Shield of Louisiana, independent licensees of the Blue Cross and Blue Shield Association.

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