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Pharmacy Prior Authorization Forms
Pharmacy prior authorization forms are used by providers and are to be used when
requesting coverage for drugs that require prior authorization. These forms are
in portable document format (PDF). You may print and copy them as needed.
For more information call 501-378-3392.
You can fax the forms to 501-378-6980.
Click on a link below to see the full list of forms available.
If the prescribed medication is not listed below please use the generic form (58 KB PDF).
Medications That Require Prior Authorization
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