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Nebraska Medicaid Rx PA: Medical Necessity Form

Nebraska Medicaid's pharmacy benefit manager, Prime Therapeutics State Government Solutions, uses this general form for fee-for-service drug prior authorization when no drug-specific form applies. Prescribers meet it for preferred drug list exceptions, quantity limit requests and high-dose overrides. The form asks why the requested drug is medically necessary compared with another covered alternative, and the Department may request chart notes to verify the answers.

Who completes it

The prescriber completes the whole form, from member and prescriber details (NPI and DEA number) to the drugs requested, prior alternatives and clinical justification. The prescriber's signature is required and confirms the information is accurate and verifiable in the member's records.

Submitting and payment

How to submit it
Fax the completed form to Prime Therapeutics, or mail it to Prime's Nebraska Medicaid unit; use one form per member.
Who pays
The request covers fee-for-service Nebraska Medicaid pharmacy claims only; Heritage Health managed care members go through their plan's prior authorization process.

Good to know

  • Up to four medications can be listed on page 1, each with strength and administration schedule; page 2 has a separate box for quantity limit or high-dose override requests.
  • List each alternative tried for the diagnosis with drug, dose, date and outcome, and give the member's weight in kilograms and height in centimeters.
  • Incomplete, incorrect or illegible forms delay the prior authorization process, according to the form's opening note.
  • Separate Nebraska Medicaid forms exist for Wegovy, Zepbound, buprenorphine, growth hormone, hepatitis C, hereditary angioedema, immunomodulators, children's psychotropics and CGMs.

Get the official form

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

Nebraska Medicaid Program Request for Prior Authorization: Documentation of Medical Necessity

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

When should I use the Nebraska Medicaid medical necessity PA form instead of a drug-specific form?

Use it when the drug has no dedicated form on the Nebraska Medicaid pharmacy PA forms page. Drug-specific forms exist for anti-obesity agents, buprenorphine, growth hormone, hepatitis C, hereditary angioedema, self-administered injectable immunomodulators, psychotropics for children and continuous glucose monitors for fee-for-service members.

What clinical information does the form ask for?

The diagnosis related to use, expected duration of therapy, alternatives tried for that diagnosis with dose, date and outcome, the member's weight and height, and additional pertinent information such as the clinical reasons for the drug and relevant lab values. The Department may request chart documentation to verify it.