Arkansas Medicaid Prior (Rx) Authorization Form

Updated December 31, 2021

An Arkansas Medicaid prior authorization form must be filled out and submitted to Arkansas Medicaid in order for medical offices to request State coverage for a non-preferred drug prescription. Along with this form, the medical professional should include any relevant clinical documentation that supports their justification to request coverage for a non-preferred medication. Once completed, this form should be submitted by fax to the number provided below.

Fax – 1 (800) 424-7976

Preferred Drug List – List used by the State to classify their approved prescription drugs

How to Write

Step 1 – First, enter the requestor’s full name and title into the indicated field.

Step 2 – Next, in the “Beneficiary Information” section, provide the patient’s full name, Medicaid ID number, date of birth, and their pharmacy’s fax number.

Step 3 – In the “Prescriber Information” section, you must supply the prescriber’s full name, NPI number, DEA number, phone number, and fax number.

Step 4 – Beneath “Medication Requested,” you will need to enter the name and strength of the medication being prescribed, as well as the relevant diagnosis.

Step 5 – Handwrite your signature and enter the date at the bottom of the page. You must attach any medical documents and written justification relevant to your request when submitting this form.