APPLICATION FORM FOR PHARMACY BENEFIT MANAGER REGISTRATION (Form 10-242)

This government document is issued by Department of Managed Health Care for use in California

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CALIFORNIA HEALTH AND SAFETY CODE SECTION 1385.0051. California Health and Safety Code sections 1340 et seq. (the “Act”). References herein to
“Section” are to sections of the Act. KNOX-KEENE HEALTH CARE SERVICE PLAN ACT

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