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Get Beta Interferons #P-23245

An to Complete) Visit www.wellmark.com for the Wellmark Drug List for current medication tier levels and updated PA Forms Facsimile Transmittal Sheet Date: / / To: From (Prescriber s Name): Wellmark Pharmacy Services Fax Number: (866) 884-4345 Prescriber s DEA Number: Phone Number: (800) 600-8065 Prescriber s Phone Number: Prescriber s Specialty: Prescriber s Fax Numb.

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