Forms and Information
Oncology Medication Prior Authorization form
Prime Therapeutics Pharmacy Claim Inquiry Form
ARRx_Synagis_PA_Form
Xolair (Omalizumab) Statement of Medical Necessity
Selzentry (Maraviroc) Statement of Medical Necessity
Arkansas Medicaid Price Research Request Form
MedWatch Patient Information Request Form
Medication Informed Consent Document for Behavioral or Psychiatric Conditions - Clients under 18 years of age
Ingrezza or Austedo Statement of Medical Necessity
Hepatitis C Virus Medication Therapy Request Form
PA Request Form (General Request)
Adult Use of a C-II Stimulant Statement of Medical Necessity
H.P. Acthar gel (corticotropin injection) Prior Authorization (PA) Request Form
Certified Behavioral Health Agencies (BHA)
NADAC Request for Medicaid Reimbursement Review Form
Arkansas Medicaid State Supplemental Rebate Contract Template