eForms Logo

Arkansas Medicaid Prior (Rx) Authorization Form

Arkansas Medicaid Prior (Rx) Authorization Form

Updated July 27, 2023

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