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