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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
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 231k

Cough and Cold List

Document Name File Name File Size
Arkansas Medicaid Cough and Cold List candclist.pdf 54k

Covered Labelers

Document Name File Name File Size
Covered Labelers CL.xls 160k

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 505k
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 – 2015 DRCSchedule.xls 23k

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 456k

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 UpperLimit 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 176k

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 491k

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