After completing the information below please fax to Empower Healthcare Solutions. Fax: 1-866-546-0484. For questions call: 1-844-865-7829.
- Arkansas Medicaid Prescription Drug Program Statement of Medical Necessity Prior Authorization Request
- Arkansas Medicaid Prior Authorization Request Form (General Request)
- Arkansas Medicaid Prescription Drug Program Synagis Prior Authorization Request Form
- Arkansas Medicaid Prior Authorization Request Form – Synagis
- Arkansas Medicaid Prescription Drug Program Hepatitis C Virus (HCV) Medication Therapy PA Request Form
- Arkansas Medicaid Prior Authorization Request Form – Hepatitis C Virus (HCV) Medication Therapy
- Statement of Medical Necessity Information Form for Ingrezza or Austedo
- Ingrezza or Austedo Statement of Medical Necessity Form
- Arkansas Medicaid Prescription Drug Program Selzentry Statement of Medical Necessity
- Selzentry (maraviroc) Statement of Medical Necessity Form
- Arkansas Medicaid Medication Assisted Treatment (MAT) Pharmocotherapy Injectable Buprenorphine-Containing Agents
- Sublocade and Probuphine (buprenorphine injectable) Statement of Medical Necessity Form
- Arkansas Medicaid Medication Assist Treatment (MAT) Pharmacotherapy VIVITROL IM
- Vivitrol (naltrexone ER) Injection Statement of Medical Necessity Form
- Arkansas Medicaid Prior Authorization Request Form H.P. Acthar gel (cortiocotropin injection)
- Arkansas Medicaid Prior Authorization Request Form – H.P. Acthar Gel
- Arkansas Medicaid Prescription Drug Program Statement of Medical Necessity for Xolair
- Xolair (omalizumab) Statement of Medical Necessity Form
- Statement of Medical Necessity for Adult use of a C-II Stimulant
- Adult Use of a C-II Stimulant Statement of Medical Necessity
- Mail Order Forms
- Claim Forms – English
- Claim Forms – Spanish
- Medication Informed Consent