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PA Request Forms

The following forms will be posted soon. 

  • Antiemetic Agents
  • Antinarcolepsy (Provigil and Nuvigil)
  • Antinarcolepsy (Sunosi)
  • Antinarcolepsy (Wakix)
  • Antinarcolepsy (Xyrem and Xywaz)
  • Austedo for Movement Disorders
  • Cialis
  • Continuous Glucose Monitors
  • Crinone
  • Cystic Fibrosis
  • Dupixent for Asthma
  • Dupixent for Atopic Dermatitis
  • Dupixent for Nasal Polyps
  • Emflaza
  • Entresto
  • Epidiolex
  • Epinephrine Pens
  • Evrysdi
  • Exondys 51
  • Fasenra
  • Gattex
  • Gocovri and Osmolex ER
  • Growth Hormone (Adult)
  • Growth Hormone (child)
  • Hematinics
  • Hepatitis C
  • Hetlioz
  • Immonomodulators
  • Ingrezza for Movement Disorders
  • Ivermectin
  • Juxtapid
  • Lupus Medications
  • Medical Exceptions
  • Migraine Calcitonin Gene Related Therapy
  • Migraine Calcitonin Agents (Ubrelvy, Nurtec)
  • Neuromuscular Blocking Agents
  • Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old
  • Nucala
  • Opioid Analgesics (Short and Long-Acting)
  • Opioid Dependence Therapy Agents
  • PCSK9 Inhibitors
  • Sedative Hypnotics
  • Selective Constipation Agents (Relistor)
  • Standard Drug Request Form
  • Standard Appeal Request Form
  • Synagis
  • Topical Antihistamines
  • Topical Anti-Inflammatory
  • Topical Local Anesthetic (Lidoderm Patch, lidocaine patch, and ZT Lido)
  • Triptans
  • Vusion
  • Xenazine and tetrabenazine for Movement Disorders
  • Xolair
  • Zolgensma

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    828-225-2785 ext. 1512
  • 200 Ridgefield Court Asheville, NC 28806

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