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Prescription drug information

Prescription Drug Information

If you have pharmacy claim or prescription drug prior authorization concerns, please call the Prescription Drug PA Help Desk:
In-state toll free:
(800) 707-3854
Local and out-of-state:
(501) 374-6609 x 500 

The documents listed in the tables below are in Microsoft Word format (.doc or .rtf), Microsoft Excel format (.xls), or portable document format (.pdf). When you click the link, the document opens in a new window. To return to this page, close the window.

If you click a link and the document doesn't open, download Microsoft Word Viewer, download Microsoft Excel Viewer, or download Adobe Acrobat Reader free so you can view and print the documents.

e-Prescribing Project Overview
Antipsychotics for Beneficiaries Less Than 18 years of Age
Capped Upper Limits
Cough and Cold List
Covered Labelers
Emergency Override
Evidence-Based Prescription Drug Program (PDL)
   View PDL Provider Notifications
   View PDL Manufacturer Information
   View Additional PDL Information
Exclusions From Coverage
Extension of Benefit
Generic Upper Limits
Informed Consent Documentation
Hepatitis C Virus Medication Therapy Request Form
Medicare Part D Excluded—Allowed by Arkansas Medicaid
MedWatch Forms and Information
Over-the-Counter List
Pharmacy Administered Vaccines
Prescriber Enrollment
Prescription Drug Claim Edits
Prescription Drug Clinical Edits
Prescription Drug Prior Authorization (PA) Forms
Provider Memorandums for Drug Edits
TB Aid Category Related Services
Tobacco Cessation Programs
Voice Response System Brochure

e-Prescribing Project Overview

If you are interested in implementing e-prescribing in your office, information
is available to help you. Get more information about e-prescribing.

Antipsychotics for Beneficiaries Less Than 18 Years of Age

Document Name

File Name

File Size

Prior Authorization Criteria

PACriteria.pdf

1.8MB

Memorandum Regarding Antipsychotics for Beneficiaries Less Than 18 Years of Age

ProvMem-003-11.doc

369k

Medication Informed Consent Document for Behavioral or Psychiatric Conditions

Capped Upper Limits

Document Name

File Name

File Size

Arkansas Medicaid CAP List

cul.pdf

227k

Cough and Cold List

Document Name

File Name

File Size

Arkansas Medicaid Cough and Cold List

candclist.pdf

50k

Covered Labelers

Document Name

File Name

File Size

Covered Labelers

CL.xls

158k

Emergency Override

In an emergency, for those drugs for which a five-day supply can be dispensed, a pharmacy may dispense up to a five-day supply of a drug that requires clinical criteria or is non-preferred. This provision applies only in an emergency situation and when the HP Enterprise Services Prescription Drug Help Desk is unavailable, Evidence Based Prescription Drug Program Help Desk is unavailable, or the pharmacist is not able to contact the prescribing physician. To file a claim using this emergency provision, the pharmacy provider will submit a “03” in the Level of Service (418-DI) field. Frequency of the emergency override is limited to once per year per class for non-LTC beneficiaries and once per 60 days per class for LTC beneficiaries.

Evidence-Based Prescription Drug Program (PDL)

View the Official Notice regarding the Evidence-Based Preferred Drug List.

Evidence-Based Prescription Drug Program (PDL)

File Name

File Size

Preferred and Non-Preferred Drug List

PDL.xls

503k

Program Overview for Arkansas Medicaid Evidence-Based Prescription Drug Program

ProgramOverview.pdf

18k

Prior Authorization Criteria

PACriteria.pdf

1.8MB

Drug Review Committee (DRC) Meeting Schedule – April 2014 through December 2014

DRCSchedule.xls

40k

View PDL Provider Notifications.
View PDL Manufacturer Information.
View Additional PDL Information.

Exclusions From Coverage

Document Name

File Name

File Size

Exclusions From Coverage

Exclusions.pdf

32k

View CMS Mandated Product Deletions.

Extension of Benefit

Document Name

File Name

File Size

Pharmacy Extension of Benefit Criteria

EOB.pdf

35k

Generic Upper Limits

Document Name

File Name

File Size

Generic Upper Limits

gul.doc

336k

Medicare Part D Excluded—Allowed by Arkansas Medicaid

Document Name

File Name

File Size

Medicare Part D Excluded–Allowed by Arkansas Medicaid

1927d.pdf

46k

MedWatch Forms and Information

Document Name

File Name

File Size

Documentation of Medical Necessity for Brand Name Drugs with a Generic Upper Limit

MWdescription.pdf

133k

MedWatch Patient Information Request Form

ptrequest.pdf

28k

Submitting MedWatch Documentation for Review 
Get FDA MedWatch forms online at: http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Forms/UCM163919.pdf (PDF, new window)

Fax or mail completed FDA MedWatch Form and MedWatch Patient Information Request Form to:

(501) 372-2971 fax

HP Enterprise Services Pharmacy Unit
P. O. Box 8036
Little Rock, AR 72203
Return to list

Over-the-Counter List

Document Name

File Name

File Size

Arkansas Medicaid Covered OTC List

otclist.pdf

37k

Pharmacy Administered Vaccines

Document Name

File Name

File Size

Pharmacy Administered Vaccines Billing Instructions

RxVaccine.pdf

154k

Prescriber Enrollment

Effective July 1st, 2013, a new Federal regulation requires that prescribing providers must be enrolled in the state's Medicaid program before a prescription can be paid by Medicaid.

Document Name

File Name

File Size

Arkansas Medicaid Prescriber Enrollment Information

Enrollment.pdf

122k

Prescription Drug Claim Edits

Document

File Name

File Size

Fiscal Integrity Edits and Audits

ClaimEdits.xls

467k

Prescription Drug Clinical Edits

Document

File Name

File Size

Prior Authorization Criteria

PACriteria.pdf

1.8MB

Memorandum Regarding Prescription Drug Clinical Edits System Enhancement

Memo.doc

47k

Tobacco Cessation Programs

Document Name

File Name

File Size

Public Health Service (PHS) Guideline-Based Check List

guideline.doc

31k

Clinical Practice Guideline

ClinicalPracGuide.pdf

1.8MB

Memo to Certified Nurse-Midwife, Child Health Services (EPSDT), Federally Qualified Health Center (FQHC), Hospital, Nurse Practitioner, Pharmacy, Physician, Rural Health Clinic, and Arkansas Division of Health providers regarding Transition of Products for Smoking Cessation from Voice Response System to Electronic Point of Sale (POS) System Modification

MemoSmokCess.doc

136k

Official notice DMS-2004-W-3 Coverage of Tobacco Cessation Products through the Arkansas Medicaid Prescription Drug Program

DMS-04-W-3.doc

196k

Pharmacy Provider Manual Update Transmittal #100 to include coverage of Chantix® (Varenicline) to the tobacco cessation products through the Arkansas Medicaid Prescription Drug Program

PHARMACY_100.pdf

57k

Voice Response System Brochure

Use these instructions to get prior authorization for restricted medications through the telephone voice response system.

Document Name

File Name

File Size

Voice Response System (VRS) Brochure

VRS.pdf

76k