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11 mcg 8. 8 mcg STEP 6 Complete Insurance Information No insurance Primary Insurance Cardholder ID Group Insurance card/cards attached front and back Name of Pharmacy Benefit Manager Does this patient have a separate pharmacy benefit card Yes No Is there a pharmacy where you would like MSLL to send this prescription Yes PRIMARY DIAGNOSIS ICD-10 code G35 I certify the prescribed therapy is medically necessary for the treatment of relapsing forms of multiple sclerosis and that this information is...
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