Adjunctive Medications Forms

These medications must be prescribed by a physician in conjunction with state certified chemical dependency treatment and require a completed authorization form for Medicaid payment. 

• Buprenorphine/Suboxone Authorization Form (DSHS 13-720)
• Campral Authorization Form (DSHS 13-749)
• ReVia Authorization Form (DSHS 13-677)
• Buprenorphine/Suboxone Exemption Request Form (DSHS 13-750)
• Vivitrol IM Physician Prior Authorization Form (DSHS 13-791) [PDF] or [Word]
  
  Shortcut to Adjunctive Medications webpage (info re opiate treatment and alcoholism)

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