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Arkansas Medicaid Statement of Medical Necessity PA

Arkansas Medicaid fee-for-service prescribers use this two-page Statement of Medical Necessity to request prior authorization for a drug that has no drug-specific form. It asks for diagnoses with ICD-10 codes, prior medication trials with dates, response and reason for failure, adherence attestations, and relevant labs or other clinical justification. Prime Therapeutics handles pharmacy prior authorization for the Arkansas Department of Human Services.

Who completes it

The prescriber completes the whole form, including NPI and DEA number, and signs the attestation confirming the information is accurate and verifiable by patient records.

Submitting and payment

How to submit it
Fax the form to Prime Therapeutics, using one form per beneficiary, or submit electronically through CoverMyMeds ePA.

Good to know

  • The prescriber attests that previous trials were adequate or stopped for an adverse event, and that failures of preferred drugs are documented in the record, which is subject to audit.
  • Lab results with dates are required when needed to establish the diagnosis or evaluate response; renewal requests ask for the treatment start date.
  • Drug-specific forms exist for oncology drugs, physician-administered drugs, CGMs, Acthar, Ingrezza or Austedo, Xolair and Selzentry, among others on the Prime Therapeutics Arkansas portal.
  • Many Arkansas Medicaid members are enrolled in PASSE plans, which run their own processes. The current form revision is 04/24/2025.

Get the official form

Download the current version from the source each time; forms change without notice.

Arkansas Medicaid Prescription Drug Program Statement of Medical Necessity Prior Authorization Request

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who handles Arkansas Medicaid pharmacy prior authorization?

Prime Therapeutics administers prior authorization for the Arkansas Medicaid Prescription Drug Program's fee-for-service beneficiaries. Its Arkansas portal posts the general request form and drug-specific forms, and requests can be faxed or sent electronically through CoverMyMeds.

Does the Arkansas general PA form apply to PASSE members?

Many Arkansas Medicaid members are enrolled in PASSE plans, which have their own processes. This Statement of Medical Necessity is for the Medicaid fee-for-service prescription drug program administered by Prime Therapeutics.

What clinical information does the Arkansas PA form ask for?

Relevant diagnoses with ICD-10 codes, other medications tried with dosage, dates, response and reason for failure or allergy, plus symptoms, dated lab results, and justification for initial or ongoing therapy or a dose increase, including any contraindication to the preferred drug.