OFFICE NAME, MEDICATION, MEDICATION DOSAGE, PATIENT NAME, PHARMACY/TREATMENT CENTER NAME, PHARMACY/TREATMENT CENTER PHONE NUMBER, CORRESPONDING BRAND PATIENT APP CODE, SINGLE USE PRESCRIBER IDENTIFIER, BRAND HUB PATIENT SUPPORT LINE, BENEFIT PRE-AUTHORIZATION DATE OR BENEFIT PENDING DATE, PRESCRIBER NAME, PRIOR AUTHORIZATION NUMBER OR PENDING TRACKING CODE, DATE PRE-AUTHORIZATION BENEFIT EXPIRES IF UNCLAIMED, ESTIMATED PATIENT OUT-OF-POCKET COST, REMAINING PATIENT DEDUCTIBLE

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