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Submit request via Fax 1-844-679-5366 Prescribing physician Name NPI Specialty Phone Fax Address Contact Person at Office o Beneficiary Medicaid ID Date of Birth Sex Pharmacy Name Pharmacy NPI Pharmacy Phone Pharmacy Fax Patient diagnosis moderate to severe persistent asthma severe persistent asthma Medication from each of the following classes must have been tried and failed prior to consideration Therapy Specific Drug Reason for discontinuation Date Inhaled Corticosteroid Leukotriene...

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