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
ARRx_Synagis_PA_Form
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
Magellan Pharmacy Claim Inquiry Form
MAT PA Form Sublocade and Vivitrol final
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
PA Request Form (General Request)
Selzentry (Maraviroc) Statement of Medical Necessity
Xolair (Omalizumab) Statement of Medical Necessity
Adult Use of a C-II Stimulant Statement of Medical Necessity
Arkansas Medicaid Price Research Request Form
Arkansas Medicaid State Supplemental Rebate Contract Template
ARRx_Synagis_PA_Form
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
Magellan Pharmacy Claim Inquiry Form
MAT PA Form Sublocade and Vivitrol final
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
PA Request Form (General Request)
Selzentry (Maraviroc) Statement of Medical Necessity
Xolair (Omalizumab) Statement of Medical Necessity