Description File
Memorandum regarding antipsychotics for beneficiaries less than 18 years of age - 05/26/2021 ProvMem-20210526
Memorandum regarding antipsychotics for beneficiaries less than 18 years of age - 01/08/2016  ProvMem-20160108

Effective April 1, 2017, Arkansas Medicaid will be utilizing a new pricing methodology for the reimbursement of covered outpatient legend and non-legend drugs. CMS has mandated that all state Medicaid programs can no longer utilize AWP pricing and must move towards a more accurate actual acquisition cost methodology. The Arkansas Medicaid lesser of methodology will price claims off Usual and Customary, National Average Drug Acquisition Cost (NADAC) rates (in cases where the NADAC is terminated or is not reported, WAC may be used as a backup) and all ACA FUL rates and SAAC (State Actual Acquisition Cost previously referred to as State MAC) rates will still apply. The Professional Dispensing Fee will be increased to $9 for Brand and Non-Preferred Brand drugs and $10.50 for Generics and Brand Preferred drugs. Claims submitted for a date of service on or after 04/01/2017 will use the new pricing methodology and dispensing fees. Claims submitted for a date of service prior to 04/01/2017 will use the old pricing methodology (AWP) and dispensing fee ($5.51). Please refer to Section II of the Pharmacy Provider Manual to view the fully detailed reimbursement methodology.

ACA FUL rates are updated monthly and NADAC rates are calculated monthly but can change on a weekly basis. NADAC rates that potentially change are released on Wednesdays. Most common reasons a NADAC may change weekly instead of monthly may be due to provider inquiry to the NADAC Help Desk or the WAC rate changes on a brand drug which triggers the Brand NADAC to be recalculated. Arkansas Medicaid gets the drug file reported to them on a weekly basis from First Data Bank and is generally loaded on Saturday nights. The effective date of any ACA FUL or NADAC on the file will be backdated in our system to reflect the effective date on the weekly drug file in which it was reported. If a NADAC rate is published on 04/12/2017 that has an effective date of 04/01/2017, when Arkansas Medicaid loads the drug file the following weekend on 04/15/2017, we will load the retro effective date of 04/01/2017 so that any claim can be resubmitted by the provider manually to process off the updated rate.

All ACA FUL and NADAC rates are available for anyone to view at https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html

To aid pharmacy providers, Arkansas Medicaid has created an informational sheet on the NADAC Request for Medicaid Reimbursement Review form below. This informational sheet is not affiliated to Myers and Stauffer LLC in any way as it is just an aid and should not be submitted to the NADAC Help Desk as part of their review inquiry. All NADAC forms needs to be submitted to Myers and Stauffer LLC but copied to Arkansas Medicaid to prove you have filed your issue with Myers and Stauffer LLC.

NADAC Help Desk:
Toll-free phone: (855) 457-5264
Electronic mail:
info@mslcrps.com
Facsimile: (844) 860-0236

Description File
Arkansas Medicaid CAP List cul.pdf
Arkansas Medicaid Price Research Request Form AR_Medicaid_SMAC_Price_Research_Request_Form
Description File
Arkansas Medicaid Cough and Cold List candclist.pdf
Description File
Covered Labelers ARRx_covered_labelers.pdf

In an emergency, for those drugs for which a five-day supply can be dispensed, an Arkansas Medicaid enrolled pharmacy may dispense up to a five-day supply of a drug that requires prior authorization. This provision applies only in an emergency situation when the MMA Prescription Drug Help Desk and the State Medicaid Pharmacy Program offices are closed, and the pharmacist is not able to contact the prescribing provider to change the prescription. The Emergency Supply Policy does not apply to drugs that are not covered by the State. Frequency of the emergency override is limited to once per year per drug class for non-LTC beneficiaries and once per 60 days per drug class for LTC beneficiaries. To file a claim using this emergency provision, the pharmacy provider will submit a “03” in the Level of Service (418 DI) field.

Get more information about e-prescribing by referring to the "e-prescribing project overview" tab.

Description File
Evidence-Based Prescription Drug Program Overview PDL_Overview.pdf
Preferred Drug List PDL.pdf
Prior Authorization Criteria PACriteria.pdf
General medication Coverage Policy General medication Coverage Policy.pdf

 

For more information, refer to the PDL Provider Notifications, PDL Manufacturer Information and Additional PDL Information sections in the "Additional Prescription Drug Information" tab.

View CMS Mandated Production Deletions.

Description File
Exclusions from Coverage Exclusions.pdf
Description File
Pharmacy Extension of Benefit Criteria EOB.pdf
Extension of Benefit - Act 758 EOB_758.pdf
Description File
Generic Upper Limits gul.pdf
Description File
Medicare Part D Excluded—Allowed by Arkansas Medicaid 1927d.pdf
Description File
Documentation of Medical Necessity for Brand Name Drugs with a Generic UpperLimit MWdescription.pdf
MedWatch Patient Information Request Form ptrequest.pdf

 

Submitting MedWatch Documentation for Review

Get FDA MedWatch forms online at: MedWatch Forms for FDA Safety Reporting - Expires 06/30/2025

Fax completed FDA MedWatch Form and MedWatch Patient Information Request Form to (800) 424-7976

Description File
NCPDP VERSION D.0 Claim Billing/Claim Re-Bill Template – Medicaid ARRx_D0_Payer_Sheet.pdf
Description File
Arkansas Medicaid Covered OTC List otclist.pdf
Description File
Pharmacy Administered Vaccines Billing Instructions ARRx_Pharmacy_Administered_Vaccines.pdf
Pharmacy Administered Vaccine Information 2020 Pharmacy_Administered_Vaccine_Information_2020
Covid-19 Antigen detection testing  Covid19_Antigen_detection_testing 
Pharmacy Administered Vaccine Place of Service Code Pharmacy_Administered_Vaccine_Place_of_Service_Code
Provider Memorandum 07/27/2021 Provider_Memorandum_07272021
Provider memorandum 12/08/2020 Provider_Memorandum_12082020
Provider memorandum 07/01/2020 Provider_Memorandum_07012020
Description File
Fiscal Integrity Edits and Audits ClaimEdits.pdf
Claim Edits Max Quantity Blood Pressure Medication BP medication
Claim Edits Max Quantity Diabetes Medication Diabetes medication
Claim Edits Max Quantity Cholesterol Medications Cholesterol medication
Claim Edits Max Quantity Blood Modifiers Blood modifiers
Description File
Prior Authorization Criteria PACriteria.pdf
Memorandum Regarding Prescription Drug Clinical Edits System Enhancement Memo.doc
Description File
Certified Behavioral Health Agencies (BHA) ARDHS_DPSQA_Certified_Behavioral_Health_Agencies.pdf
Hepatitis C Virus Medication Therapy Request Form HepCTreatmntForm.pdf
Ingrezza™ or Austedo® Statement of Medical Necessity ARRx_SMN_Form_Ingrezza_Austedo.pdf
Invega Trinza™ Statement of Medical Necessity ARRx_SMN_Form_Invega_Trinza.pdf
Medication Informed Consent Document for Behavioral or Psychiatric Conditions MedInformedConsent.pdf
PA Request Form (General Request) ARRx_PA_Request_Form.pdf
Selzentry® (Maraviroc) Statement of Medical Necessity selzentry.pdf
Synagis® Prior Authorization (PA) Request Form ARRx_Synagis_PA_Form.pdf
Xolair® (Omalizumab) Statement of Medical Necessity xolair.pdf
H.P. Acthar gel (corticotropin injection) PA Request Form Acthar_gel.pdf
Statement of Medical Necessity - Adult C-II Stimulant Adult_C_II_Stimulant.pdf

For Provider Reconsiderations:

A provider may request an administrative reconsideration within 30 calendar days. Requests for reconsideration should be faxed to (501)683-4124 Attn: Medicaid Pharmacy Program. For more information, please consult §160.000 of the program manual. Only one reconsideration request is permitted.

 

For Provider and Beneficiary Appeals:

If you disagree with our decision, you may ask for an appeal hearing from the Office of Appeals and Hearings. To ask for a hearing you must send your request in writing within 30 calendar days to the Office of Appeals and Hearings, P.O. Box 1437, Slot N401, Little Rock, AR 72203-1437. You must enclose a copy of the denial letter and a copy of the envelope containing the denial letter or enclose a copy of the denial letter showing the facsimile transmission confirmation with your request. If you do not include those copies, your appeal will be delayed. All deadlines run from the next business day after the date of the postmark on the envelope containing this letter or the next business day after the date on the facsimile transmission confirmation. All appeals shall conform to the Arkansas Administrative Procedure Act, Ark. Code Ann. §§ 25-15-201 – 25-15-218. Providers may appear in person, through a corporate representative or, with prior notice to the department, through legal counsel. Beneficiaries may represent themselves or they may be represented by a friend, by any other spokesperson except a corporation, or by legal counsel. A Medicaid beneficiary may attend any hearing related to his or her care, but the department may not make his or her participation a requirement for provider appeals. The department may compel the beneficiary’s presence via subpoena, but failure of the beneficiary to appear shall not preclude the provider’s appeal. If an administrative appeal is filed by both a provider and beneficiary concerning the same subject matter, the department may consolidate the appeals. Any person who considers himself or herself injured in his or her person, business, or property by the decision rendered in the administrative appeal is entitled to judicial review of the decision under the Arkansas Administrative Procedure Act, Ark. Code Ann. §§ 25-15-201 – 25-15-218. For more information, please consult §160.000 of the program manual.

After a brand name drug’s patent has expired there may be a company producing a generic drug that meets the FDA’s criteria for the “181-day generic drug exclusivity”, which means it is protected from competition from other generic versions of the same drug product for approximately 181 days. After the expiration of the 181-day exclusivity period, other generic companies may be poised to enter the market and as more generic drugs are available, the price begins to fall.
The state Medicaid pharmacy program staff will monitor these high cost brand-name drugs and check the Federal rebate file to determine the most economical choice for the state, either:

  • The brand name drug due to a higher Federal rebate and lower final net cost to the state -- or
  • The generic drug that likely has the 181-day generic exclusivity without other generic competition

When there is sufficient supply of the generic drugs and the price of the generics has fallen to less than the final net cost of the brand name drug, the generic may be the most cost effective choice for the state. At that time, the Medicaid staff may place a State Maximum Allowable Cost (MAC) on both the brand and the generic drugs for that specific drug/strength/dosage form. Until that occurs, Arkansas Medicaid will require the Brand drug to continue to be dispensed by pharmacies. Please note clinical criteria and claim edits will still apply. Pharmacies will receive a 30-day notice prior to Arkansas Medicaid applying a MAC on the brand and generic drugs related to State Supported Brand Medications.

Description File
State Supported Brand Medications Document State_Supported_Brand_Meds.pdf
Description File
Coverage of Tobacco Cessation Products as of 1/1/2020 Tobacco_Cessation.pdf
Public Health Service (PHS) Guideline-Based Check List guideline.doc
Clinical Practice Guideline ClinicalPracGuide.pdf
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
Official notice DMS-2004-W-3 Coverage of Tobacco Cessation Products through the Arkansas Medicaid Prescription Drug Program DMS-04-W-3.doc
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
Description File
UAC Administrative Org Scenarios UAC_Administrative_Org_Scenarios.pdf
State of Arkansas Provider Frequently Asked Questions Train_AR_Provider_FAQs.pdf
Description File
Voice Response System (VRS) Brochure VRS.pdf
Date Description File
05/09/16 Evidenced-Based Prescription Drug List (PDL) re-review of Long-Acting Opioid Analgesic Agents

ARRx_Notification_20160509

12/11/15 Evidenced-Based Prescription Drug List (PDL) re-review of Angiotensin II Receptor Blocker (ARB), Angiotensin-Converting Enzyme Inhibitors ( ACEI), and Direct Renin Inhibitor (DRI) agents

ARRx_Notification_20151211

02/09/15 Evidenced-Based Prescription Drug List (PDL) re-review of Targeted Immune Modulators (TIMS)

ARRx_Notification_20150209

12/05/14 Evidenced-Based Prescription Drug List (PDL) re-review of ADHD drugs

ARRx_Notification_20141205

07/21/14 Provider Notification for Quick Relief Meds for Asthma (QRMA)

pdlQRMA

07/21/14 Provider Notification on Changes in Asthma Controller Meds

pdlCMA

06/16/14 Provider Notification for Change in Preferred Status of Anticholinergic Agents to Treat Overactive Bladder (OAB) Syndrome

pdlOABmeds

06/16/14 Provider Notification for Change in Preferred Status of HMG-CoA Reductase Inhibitor (“Statins”) Drug Class

pdlStatinsFDCPhyperlipid

05/06/14 Provider Notification for Disease-Modifying Agents for Multiple Sclerosis

pdlMSagents

05/06/14 Provider Notification on Second Generation Antidepressant Drug Class

pdlSGAD

05/06/13 Provider Notification on Change in Preferred Status of PPI Drug Class

pdlPPI

05/07/13 Provider Notification on Changes in Angiotensin II Receptor Blocker (ARB) and Direct Renin Inhibitor (DRI) Agents (Updated 3/1/13 - aliskiren (Tekturna®) and aliskiren/HCTZ (Tekturna HCT®) were inadvertently left out of the previous version of this notification but are now correctly included in the preferred drug list.)

pdlARBagents

07/16/12 Provider Notification for Re-review of Inhaled Nasal Corticosteroid Agents

pdlNCSreview

07/01/12 Provider Notification of Preferred Agents in TIMs Drug class

pdlTIMs

04/17/12 Provider Notification for Re-Review of ADD/ADHD Agents

pdlADD-ADHD

02/28/12 Provider Notification on Newer Drugs for Insomnia

pdlInsomniaReview

01/10/12 Provider Notification on Changes in the Long-Acting Opioid Analgesics Meds

pdlLAO

01/01/12 Provider Notification on Changes in Preferred Status on Non-Insulin Anti-Diabetic Agents

pdlDiabetes

12/31/11 Provider Notification on Changes in Meds for Neuropathic Pain

pdlNP

09/19/11 Provider Notification on Drugs Used for Treating Fibromyalgia

pdlFIBRO

07/07/11 Provider Notification on Changes for Oral and Topical NSAID Agents

pdlNSAIDs

12/28/10 Provider Notification on Second Generation Oral Antihistamines and Nasal Spray Antihistamines

pdlAntihistamines

08/17/10 Provider Notification of Changes to CCB Preferred Drug

pdlCCBagents

08/17/10 Provider Notification of Changes to ACE-Inhibitors, ARB, and DRI Agents

pdlACEI_ARB_DRI

07/01/10 Provider Notification on Changes in Preferred Status of Triptan(Migraine) Agents

pdlTriptanReview

09/14/09 Provider Notification on Oral and Injectable Newer Antiemetic Agents(5-HT3 and NK1 Receptor Antagonists) Re-review

pdlAEMmeds

08/01/08 Provider Notification on Changes in Long-Acting Opioid Narcotic Analgesic Drug Class

pdlL-AOpioid

07/11/08 Provider Notification for Changes in Hormone Replacement Therapy(HRT) Drug Class, Including Estrogen and Estrogen-Progestin Combinations, for Women in Menopausal Transition or the Postmenopausal Stage

pdlHRTpref

06/05/08 Provider Notification for Drugs for Neuropathic Pain

pdlNeuropathicPain

12/18/07 Provider Notification on Change in Preferred Status of Beta Adrenergic Blocker Drug Class

pdlBB

01/18/06 Provider Notification on Skeletal Muscle Relaxants

pdlSklMuscRlx

Description File
    Arkansas Medicaid State Supplemental Rebate Contract Template Template
    CMS Approval of Medicaid Supplemental Rebate Agreement CMSApproval
Date Description File
04/13/13 CMS Product Deletion Non-Drug Items

NonDrugItems.doc

09/05/12 CMS Product Deletion Prodrin

Prodrin.doc

06/02/11 CMS Product Deletion Hyoscyamine

Hyoscyamine.doc

05/05/11 CMS Product Deletion Cough and Cold

Cough.doc

11/16/10 CMS Product Deletion Pruvel

Pruvel.doc

11/16/10 CMS Product Deletion Colchicine(Second)

Colchicine2.doc

10/21/10 CMS Product Deletion Colchicine

Colchicine.doc

05/10/10 CMS Product Deletion Pancreatic Enzymes

Enzymes.doc

04/08/10 CMS Product Deletion Nitroglycerin

Nitroglycerin.doc

01/25/10 CMS Product Deletion Dietary

DietaryOTC.doc

04/13/09 CMS Product Deletion Calciferol

Calciferol.doc

04/02/09 CMS Product Deletion Hylira

Hylira.doc

12/17/08 CMS Product Deletion Ferrous Sulphate

FerrousSulf.doc

12/08/08 CMS Product Deletion Labeler 49348

Labeler49348.doc

10/24/08 CMS state release #150 final

CMSRel150.doc

08/27/08 CMS Product Deletion Hydrocodone

Hydrocodone2.doc

08/27/08 CMS Product Deletion Hydrocodone

Hydrocodone.doc

08/14/08 CMS Product Deletion Guaifenesin(Third)

Guaifenesin3.doc

07/20/08 CMS Product Deletion Auralgan

Auralgan.doc

04/10/08 CMS Product Deletion Guaifenesin(Second)

Guaifenesin2.doc

04/08/08 CMS Product Deletion Guaifenesin

Guaifenesin1.doc

Date Description File
  Suggested Carisoprodol Tapering

CarisoTaper.pdf

  Opioid Dosing Conversion Calculator

OpioidDosingConversionCalculator.xls

  Conversion Chart for HMG-CoA Reductase Inhibitor Equivalent Dosing

ConversionChart.pdf

Address

Department of Human Services
Donaghey Plaza South
700 Main Street
Little Rock, AR 72201
Conference Room A

Calendar

  • April 17, 2024
  • July 17, 2024
  • Oct 16, 2024

Agenda
The agenda is in 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 Adobe Acrobat Reader free so you can view and print the document. 

DUR Board Voting Board Members:

  • Geri Bemberg, Pharm.D.
  • Clint Boone, Pharm.D.
  • Lana Gettman, Pharm.D.
  • Florin Grigorian, M.D.
  • Brian King, Pharm.D.
  • Michael Mancino, M.D.
  • Charles Marsh, Pharm.D.
  • Melissa Max, Pharm.D.
  • Laurence Miller, M.D.
  • Brenna Neumann, Pharm.D.
  • Daniel Pace, M.D.
  • Paula Podrazik, M.D.
  • Tonya Robertson, Pharm.D.
  • Chad Rodgers, M.D.
  • Open physician position

DUR Board Non-voting Board Members:

  • Karen Evans, P.D. (Magellan)
  • Lesley Irons, Pharm.D. (Magellan)
  • Barry Fielder, Pharm.D. (Arkansas Total Care)
  • Lauren Jimerson, Pharm.D. (Summit Community Care)
  • Ifeyinwa Onowu, Pharm.D. (CareSource)
  • Shannon Burke, Pharm.D. (Empower)
  • Cynthia Neuhofel, Pharm.D. (DHS)
  • Cindi Pearson, Pharm.D. (DHS)

Non-Voting and Ex-Officio Members in an Advisory Capacity:

  • William Golden, M.D. (DHS)
  • Shane David, Pharm.D. (ADH)
Description File

Conflict of Interest

DisclosureCOI.pdf

Arkansas Medicaid DUR Board Bylaws

DUR_DRC_Bylaws_October_2022.pdf

Arkansas Medicaid DUR Board Bylaws (for historical reference only)

ARRx_DUR_board_bylaws.pdf

Meeting Minutes - 01/17/24

ARRx_DUR_DRC_meeting_minutes_20240117.pdf

Meeting Agenda - 01/17/24

ARRx_DUR_DRC_meeting_agenda_20240117.pdf

Meeting Minutes - 10/18/23

ARRx_DUR_Board_meeting_minutes_20231018.pdf

Meeting Agenda - 10/18/23

ARRx_DUR_DRC_meeting_agenda_20231018.pdf

Meeting Minutes - 07/19/23

ARRx_DUR_Board_meeting_minutes_20230719.pdf

Meeting Agenda - 07/19/23

ARRx_DUR_DRC_meeting_agenda_20230719.pdf

Meeting Minutes - 04/19/23

ARRx_DUR_DRC_meeting_minutes_20230419.pdf

Meeting Agenda - 04/19/23

ARRx_DUR_DRC_meeting_agenda_20230419.pdf

Meeting Minutes - 01/18/23

ARRx_DUR_DRC_meeting_minutes_20230118.pdf

Meeting Agenda - 01/18/23

ARRx_DUR_DRC_meeting_agenda_20230118.pdf

Meeting Minutes - 10/19/22

ARRx_DUR_board_meeting_minutes_20221019.pdf

Meeting Agenda - 10/19/22

ARRx_DUR_board_meeting_agenda_20221019.pdf

Meeting Minutes - 07/20/22

ARRx_DUR_board_meeting_minutes_20220720.pdf

Meeting Agenda - 07/20/22

ARRx_DUR_board_meeting_agenda_20220720.pdf

Meeting Minutes - 04/20/22

ARRx_DUR_board_meeting_minutes_20220420.pdf

Meeting Agenda - 04/20/22

ARRx_DUR_board_meeting_agenda_20220420.pdf

Meeting Minutes - 01/19/22

ARRx_DUR_board_meeting_minutes_20220119.pdf

Meeting Agenda - 01/19/22

ARRx_DUR_board_meeting_agenda_20220119.pdf

Meeting Minutes - 10/20/21

ARRx_DUR_board_meeting_minutes_20211020.pdf

Meeting Agenda - 10/20/21

ARRx_DUR_board_meeting_agenda_20211020.pdf

Meeting Minutes - 07/21/21

ARRx_DUR_board_meeting_minutes_20210721.pdf

Meeting Agenda - 07/21/21

ARRx_DUR_board_meeting_agenda_20210721.pdf

Meeting Minutes - 04/21/21

RRx_DUR_board_meeting_minutes_20210421.pdf

Meeting Agenda - 04/21/21

ARRx_DUR_board_meeting_agenda_20210421.pdf

Meeting Minutes - 01/20/21 

ARRx_DUR_board_meeting_minutes_20210120.pdf

Meeting Agenda - 01/20/21

ARRx_DUR_board_meeting_agenda_20210120.pdf

Meeting Minutes - 10/21/20

ARRx_DUR_board_meeting_minutes_20201021.pdf

Meeting Agenda - 10/21/20 

ARRx_DUR_board_meeting_agenda_20201021.pdf

Meeting Minutes - 07/15/20

ARRx_DUR_board_meeting_minutes_20200715.pdf

Meeting Agenda - 07/15/20

ARRx_DUR_board_meeting_agenda_20200715.pdf

Meeting Minutes - 04/15/20

ARRx_DUR_board_meeting_minutes_20200415.pdf

Meeting Agenda - 04/15/20

ARRx_DUR_board_meeting_agenda_20200415.pdf

Meeting Minutes - 01/15/20

ARRx_DUR_board_meeting_minutes_20200115.pdf

Meeting Agenda - 01/15/20

ARRx_DUR_board_meeting_agenda_20200115.pdf

Meeting Minutes - 10/16/19

ARRx_DUR_board_meeting_minutes_20191016.pdf

Meeting Agenda - 10/16/19

ARRx_DUR_board_meeting_agenda_20191016.pdf

Meeting Minutes - 07/17/19

ARRx_DUR_board_meeting_minutes_20190717.pdf

Meeting Agenda - 07/17/19

ARRx_DUR_board_meeting_agenda_20190717.pdf

Meeting Minutes - 04/17/19

ARRx_DUR_board_meeting_minutes_20190417.pdf

Meeting Agenda - 04/17/19

ARRx_DUR_board_meeting_agenda_20190417.pdf

Description

File

By Laws

ARRx_DRC_bylaws.pdf

Members

ARRx_DRC_members.pdf

Meeting schedule

ARRx_DRC_meeting_schedule.pdf

Meeting Minutes - 11/09/22

ARRx_DRC_meeting_minutes_20221109.pdf

Meeting Agenda - 11/09/22

ARRx_DRC_meeting_agenda_20221109.pdf

Meeting Agenda - 08/10/22 - Cancelled

ARRx_DRC_meeting_agenda_20220810.pdf

Meeting Minutes - 05/11/22

ARRx_DRC_meeting_minutes_20220511.pdf

Meeting Agenda - 05/11/22

ARRx_DRC_meeting_agenda_20220511.pdf

Meeting Minutes - 02/09/22

ARRx_DRC_meeting_minutes_20220209.pdf

Meeting Agenda - 02/09/22

ARRx_DRC_meeting_agenda_20220209.pdf

Meeting Minutes - 11/10/21

ARRx_DRC_meeting_minutes_20211110.pdf

Meeting Agenda - 11/10/21

ARRx_DRC_meeting_agenda_20211110.pdf

Meeting Minutes - 08/11/21

ARRx_DRC_meeting_minutes_20210811.pdf

Meeting Agenda - 08/11/21

ARRx_DRC_meeting_agenda_20210811.pdf

Meeting Minutes - 05/12/21

ARRx_DRC_meeting_minutes_20210512.pdf

Meeting Agenda - 05/12/21

ARRx_DRC_meeting_agenda_20210512.pdf

Meeting Minutes - 02/10/21

ARRx_DRC_meeting_minutes_20210210.pdf

Meeting Agenda - 02/10/21

ARRx_DRC_meeting_agenda_20210210.pdf

Meeting Minutes - 11/12/20

ARRx_DRC_meeting_minutes_20201112.pdf

Meeting Agenda - 11/12/20

ARRx_DRC_meeting_agenda_20201112.pdf

Meeting Minutes - 08/12/20

ARRx_DRC_meeting_minutes_20200812.pdf

Meeting Agenda - 08/12/20

ARRx_DRC_meeting_agenda_20200812.pdf

Meeting Minutes - 05/13/20

ARRx_DRC_meeting_minutes_20200513.pdf

Meeting Agenda- 05/13/20

ARRx_DRC_meeting_agenda_20200513.pdf

Meeting Minutes - 02/12/20

ARRx_DRC_meeting_minutes_20200212.pdf

Meeting Agenda - 02/12/20

ARRx_DRC_meeting_agenda_20200212.pdf

Meeting Minutes - 11/13/19

ARRx_DRC_meeting_minutes_20191113.pdf

Meeting Agenda - 11/13/19

ARRx_DRC_meeting_agenda_20191113.pdf

Meeting Minutes - 08/14/19

ARRx_DRC_meeting_minutes_20190814.pdf

Meeting Agenda - 08/14/19

ARRx_DRC_meeting_agenda_20190814.pdf

Meeting Minutes - 05/08/19

ARRx_DRC_meeting_minutes_20190508.pdf

Meeting Agenda - 05/08/19

ARRx_DRC_meeting_agenda_20190508.pdf

Description File
Arkansas Medicaid e-Prescribing Project Overview ARRx_ePrescribing
Description File
Questions and Answers Regarding e-Prescribing ePrescribingQA.pdf
Description File
Medicaid Tamper Resistant Requirement Guidance from the Centers for Medicare and Medicaid (CMS) and the National Council for Prescription Drug Programs (NCPDP) DMS-08-A-9

These lists are informative; we do not recommend one vendor over another. 

Date Description
10/17 Volume 2, Issue 7, October 2017 - Arkansas' Upgrade to a New MMIS
09/17 Volume 2, Issue 6, September 2017 - Arkansas' Upgrade to a New MMIS
08/17 Volume 2, Issue 5, August 2017 - Arkansas' Upgrade to a New MMIS
06/17 Volume 2, Issue 4, June 2017 - Arkansas' Upgrade to a New MMIS
03/17 Volume 2, Issue 3, March 2017 - Arkansas' Upgrade to a New MMIS
02/17 Volume 2, Issue 2, February 2017 - Arkansas' Upgrade to a New MMIS
01/17 Volume 2, Issue 1, January 2017 - Arkansas' Upgrade to a New MMIS
12/16 Volume 1, Issue 2, December 2016 - Arkansas' Upgrade to a New MMIS
10/16 Volume 1, Issue 1, October 2016 - Arkansas' Upgrade to a New MMIS
Date Description
02/14/2024 The Arkansas Medicaid Pharmacy Program Provider Memorandum dated February 14, 2024 provides updates from the Arkansas Medicaid Pharmacy Program including the most recent DUR/DRC Board meeting and preferred drug list changes.AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR/DRC Board January 17, 2024 meeting for the following: 
Manual review criteria for: Furoscix® (furosemide), Imcivree® (setmelanotide), Vyjuvek™ (beremagene geperpavec), targeted immunomodulator criteria for gout flares, Sohonos™ (palovarotene), Ojjaara (momelotinib), Xdemvy™ (lotilaner), Opfolda™ (miglustat), Likmez™ (metronidazole)
Preferred Drug List (PDL) therapeutic classes without PA criteria: Ophthalmic antibiotics, otic antibiotics Preferred Drug List (PDL) therapeutic classes with PA criteria: Erythropoiesis Stimulating Agents (Epogen® (epoetin alfa), Procrit® (epoetin alfa), Aranesp® (darbepoetin alfa), Mircera® (methoxy peg-epoetin beta), Reblozyl® (luspatercept), Retacrit® (epoetin alfa)); Urea Cycle Disorders (Buphenyl® (sodium  phenylbutyrate), Carbaglu® (carglumic acid), Olpruva™ (sodium phenylbutyrate), Pheburane® (sodium phenylbutyrate), and Ravicti® (glycerol phenylbutyrate))
11/28/2023 Diabetic Supply Program Update
11/28/2023 Hepatitis C Update
11/13/2023 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR/DRC Board October 18, 2023 meeting for the following:
Manual review criteria for: Skyclarys™ (omaveloxolone), Vanflyta® (quizartinib), and Akeega™ (niraparib/abiraterone)
Preferred Drug List (PDL) therapeutic classes without PA criteria: Colony stimulating factors
Preferred Drug List (PDL) therapeutic classes with PA criteria: Movement disorder agents (Austedo®, Austedo XR®, Ingrezza®, tetrabenazine), Long-acting opioids, Lipotropics (bile acid sequestrants, fibric acid agents, PCSK9 inhibitors, ezetimibe, Nexletol®/Nexlizet®, Juxtapid®, Omega-3 fatty acids)
10/01/2023 Pharmacist Enrollment Guide for the Provider Portal
08/14/2023 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR/DRC Board July 19, 2023 meeting for the following:
Manual review criteria for: Daybue™ (trofinetide), Joenja® (leniolisib), Vowst™ (fecal microbiota spores, live-brpk), Veozah™ (fezolinetant), asthma immunomodulators class, ADD/ADHD agents for adults, narcolepsy agents, certain medications for atopic dermatitis, and certain HIV drugs.
Point-of-Sale edits for: Antidepressants, long-acting injectable antipsychotics
Preferred Drug List (PDL) therapeutic classes without PA criteria: Short-acting beta agonists (SABA)
Preferred Drug List (PDL) therapeutic classes with PA criteria: Antidepressants, long-acting injectable antipsychotics, asthma immunomodulators, ADD/ADHD agents, narcolepsy agents, medications for atopic dermatitis (topical and biologic), and HIV agents
Policy update: General Medication Coverage Policy (formerly known as New-To-Market policy)
06/19/2023 PDL updates for Vimpat® solution (locasamide)
05/9/2023 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR/DRC Board April 19, 2023 meeting for the following: Manual review criteria for: KEVZARA® (sarilumab), ALS medications, KRAZATI™ (adagrasib), SUNLENCA® (lenacapavir sodium), JAYPIRCA™ (pirtobrutinib), ORSERDU™ (elacestrant), DARTISLA ODT® 1.7 mg and GLYCATE® 1.5 mg (glycopyrrolate), FILSPARI™ (sparsentan) Point-of-Sale edits for: Pituitary suppressive agents, cystic fibrosis transmembrane conductance regulator (CFTR) agents Preferred Drug List (PDL) therapeutic classes: Anaphylaxis agents, hypoglycemic agents and pituitary suppressive agents
05/5/2023 PDL updates for Lamictal® (lamotrigine), Novolog® (insulin aspart), and Novolog Mix® (insulin aspart mix)
03/23/23 During the Arkansas Medicaid DUR/DRC Board meeting on January 18, 2023, the Board approved point-of-sale edits for montelukast. The expected date for implementation has been postponed until April 1, 2023.
02/15/23 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR/DRC Board January 18, 2023 meeting for the following:
Manual review criteria for: Vivjoa™ (oteseconazole), Enspryng® (satralizumab), multiple sclerosis class, Qutenza® (capsaicin), Lytgobi® (futibatinib), Hyftor™ (sirolimus), Rezlidhia™ (olutasedinib), and antimigraine agents (non-triptan)
Point-of-Sale edits for: leukotriene receptor antagonists
Preferred Drug List (PDL) therapeutic classes: cephalosporins, leukotriene receptor antagonists
2/1/2023 Updated Plan Prefers Brand List - Afinitor®
1/27/2023 Update to PDL Brand Preferred Product - Lantus®
1/1/2023 Cost sharing or copays will begin on 1/1/2023 for certain adult Medicaid clients. There are some exemptions, including but not limited to pregnancy-related services. The out-of-pocket costs clients may pay are small but important. The Arkansas Medicaid program covers medical costs, so clients don't have big bills after an emergency or illness.
11/23/2022 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR Board October 19, 2022 meeting for the following:
Manual review criteria for: Monoclonal antibodies (Dupixent®, Fasenra®, Nucala®, Tezspire®, Xolair®); Targeted Immunomodulators (Actemra®, Adbry®, Arcalyst®, Cibinqo®, Cimzia®, Cosentyx®, Enbrel®, Humira®, Ilaris®, Ilumya®, Kevzara®, Kineret®, Olumiant®, Orencia®, Otezla®, Rinvog®, Siliq®, Simponi®, Skyrizi®, Sotyktu®, Stelara®, Taltz®, Tremfya®, Xeljanz®); ADHD in adults; Ztalmy® (ganaxolone); Zoryve™ (roflumilast); Vtama® (tapinarof); Amvuttra™ (vutrisiran); Xaciato™ (clindamycin)
Point-of-Sale edits for: None
Preferred Drug List (PDL) therapeutic classes for DRC meeting November 9, 2022: inhaled antibiotics, non-triptan antimigraine, topical antiparasitics, inhaled long-acting beta agonists (LABA), inhaled short-acting beta agonists (SABA), inhaled long-acting muscarinic antagonists (LAMA), inhaled short-acting muscarinic antagonists (SAMA), inhaled corticosteroids (ICS), inhaled combination products (ICS/LABA), inhaled combination products (LABA/LAMA), inhaled combination products (ICS/LABA/LAMA), growth hormones, multiple sclerosis agents, pancreatic enzymes, pulmonary arterial hypertension (PAH), substance use disorder treatment (injection)
9/14/2022 Update to State Supported Brand list
9/9/2022 Upcoming product discontinuations
Multiple branded drug products will be discontinued in the near future. Some of these products are listed as preferred on the Medicaid Preferred Drug List (PDL).
8/19/2022 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR Board July 20, 2022 meeting for the following:
Manual review criteria for: Acute and prophylaxis migraine treatment, Hemophilia A treatment (Hemlibra®, NovoSeven RT, Sevenfact, FEIBA), Camzyos™ (mavacamten), Vijoice® (alpelisib), Radicava ORS (edaravone), Dupixent (dupilumab) for Eosinophilic Esophagitis
Point-of-Sale edits for: SGLT-2 inhibitors for heart failure (Farxiga® and Jardiance®), Budesonide Respules for Eosinophilic Esophagitis, age edits for benzo and non-benzo sedative hypnotics, maximum dose for targeted immunomodulators
Preferred Drug List (PDL) therapeutic classes: (August 10, 2022 Drug Review Committee meeting) Meeting was cancelled.
8/1/2022 Sedative Hypnotics in Children
5/25/2022 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR Board April 20, 2022 meeting for the following:
Manual review criteria for: Livmarli™ (maralixibat), Livtencity™ (maribavir), Tarpeyo™ (budesonide), Apretude (cabotegravir), Leqvio® (inclisiran), Recorlev® (levoketoconazole), Besremi® (ropeginterferon), Vonjo™ (pacritinib), Pyrukynd® (mitapivat), Oxervate™ (cenegermin)
Point-of-Sale edits for: Antiemetics in pregnancy (Diclegis® and Bonjesta®) (doxylamine/pyridoxine)
Preferred Drug List (PDL) therapeutic classes: (May 11, 2022 Drug Review Committee meeting) Antipsychotics, Bowel Prep Agents, Cystine Depleting Agents/Penicillamine Agents, Proton Pump Inhibitors
2/23/2022 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR Board January 19, 2022 meeting for the following:
Manual review criteria for: Palforzia® (peanut powder), Kerendia® (finerenone), Tavneos™ (avacopan), Exkivity™ (mobocertinib), Opzelura™ (ruxolitinib), Scemblix® (asciminib), Vuity™ (pilocarpine hydrochloride), Voxzogo™ (vosoritide), and Carbaglu® (carglumic acid)
Point-of-Sale edits for: Seroquel® (Quetiapine) and rescue seizure medications (Nayzilam®, Valtoco® and Diastat®)
Preferred Drug List (PDL) therapeutic classes: (February 9, 2022 Drug Review Committee meeting) Anticonvulsants and immune globulins
1/7/2022 Updated plan prefers brand list
11/24/2021 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR Board October 20, 2021 meeting for the following:
Manual review criteria for: Hidradenitis Suppurativa, palivizumab (Synagis®), ibrexafungerp (Brexafemme®), belumosudil (Rezurock™), odevixibat (Bylvay™), rifamycin (Aemcolo™), and belzutifan (Welireg™)
Point-of-Sale edits for: Immunoglobulin (IVIG and SCIG), quantity edits for antiepileptic medications, dose optimization for multiple drug classes (blood pressure, diabetes, cholesterol, and blood modifiers)
Preferred Drug List (PDL) therapeutic classes: (November 10, 2021 Drug Review Committee meeting) Antiparkinson's disease, beta blockers, neuropathic pain agents, and sedative hypnotics (benzodiazepine and non-benzodiazepine)
8/25/2021 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR Board July 21, 2021 meeting for the following:
Manual review criteria for: Hetlioz® (tasimelteon), Verquvo™ (vericiguat), Fotivda® (tivozanib), Lumakras™ (sotorasib), Empaveli™ (pegcetacoplan), and Truseltiq™ (infigratinib)
Point-of-Sale edits for: Update for ADHD medications, ICS-LABA for asthma, Lyrica® (pregabalin), soft ProDUR edits for opioids combined with benzodiazepines, sedative hypnotics, muscle relaxers, antipsychotics, or gabapentin.
General criteria info: New-to-market medications and medications with label expansions
Preferred Drug List (PDL) therapeutic classes: (August 11, 2021 Drug Review Committee meeting)
Alzheimer’s agents, benign prostatic hyperplasia agents (BPN), hemorrhoidal preparations, opiate dependence treatments (oral buprenorphine products only), and skeletal muscle relaxants
8/21/2021 Criteria for Medications New-to-Market or With Label Expansion Medications
8/10/2021 Temporary Increase in Arkansas Medicaid COVID-19 Vaccination Administration Rate
7/27/2021 COVID-19 Vaccination Rates and Billing Codes
6/28/2021 Update for declaration of public health emergency for COVID-19
5/26/2021 AR Medicaid Prior Authorization Edits approved at the AR Medicaid DUR Board April 21, 2021 meeting for the following:
Manual review criteria for: Ukoniq™ (umbralisib); Nexletol™ (bempedoic acid); Cabenuva (cabotegravir and rilpivirine); Bronchitol® (mannitol); Tepmetko® (tepotinib); Lupkynis™ (voclosporin); Benlysta® (belimumab); Orgovyx™ (relugolix); Orladeyo™ (berotralstat); SGLT-2 inhibitors for heart failure (Farxiga® and Jardiance®);
Updated point-of-sale edit (effective July 14, 2021): Otezla® (apremilast); GI motility (Amitiza®, Linzess®, and Movantik®);
Updated PA form: Informed consent form for children on antipsychotics
Preferred Drug List (PDL) therapeutic classes from the May 12, 2021 Drug Review Committee meeting for the following: Colony Stimulating Factors; Lipotropic Agents (statins); Narcolepsy Agents (Provigil/Nuvigil only); Phosphate Binders; and Platelet Aggregation Inhibitors
2/24/2021 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board January 20, 2021 meeting for the following:
Manual review criteria for: Isotretinoin, GnRH Receptor Antagonists (Orilissa® and Oriahnn™), Thrombopoiesis Stimulating Proteins (Promacta®, Mulpleta®, Doptelet®, and Tavalisse™), Immunomodulators for Asthma (Fasenra®, Dupixent®, Xolair®, and Nucala®), Xpovio® (Selinexor), Gavreto™ (pralsetinib), Ongentys™ (opicapone), Onureg® (azacitidine), and Zokinvy (lonafarnib).
Preferred Drug List (PDL) therapeutic classes from the February 10, 2021 Drug Review Committee Meeting for the following:
Anticoagulants, Antihyperuricemics, Estrogen Agents, GI Motility Agents, and Hepatitis C Agents
2/8/2021 New ADHD Edits Beginning February 10, 2021
12/8/2020 COVID-19 Vaccination Rates and Billing Codes
11/25/2020 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board October 21, 2020 meeting for the following:
Manual review criteria for: Palforzia™ (peanut allergy), Fasenra® (benralizumab) injection, Qinlock™ (ripretinib) tablet, Kynmobi™ (apomorphine hydrochloride) SL films, Fintepla® (fenfluramine) oral solution, Evyrsdi™ (risdiplam) powder, Enspryng™ (satralizumab) injection, Inqovi® (cedazuridine and decitabine) tablet, Oral CGRP antagonists (Ubrelvy™ and Nurtec™ ODT), and Dojolvi® (triheptanoin) liquid;
Point-of-sale and claim edit updates: CII stimulant update and controlled drug early refill threshold update
Preferred Drug List (PDL) therapeutic classes from the November 12, 2020 Drug Review Committee Meeting for the following:
Angiotensin modulators (ACE inhibitors, ARBs, renin inhibitors, and combination products), calcium channel blockers, cytokine and CAM antagonists (targeted immune modulators), immunomodulators for asthma, stimulants and related agents, and thrombopoiesis stimulating proteins.
8/26/2020 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board July 15, 2020 meeting for the following:
Manual review criteria for: Repatha® (evolocumab), Praluent® (alirocumab), Acthar® gel (repository corticotropin), Isturisa® (osilodrostat), Koselugo™ (selumetinib), Tukysa™ (tucatinib), Pemazyre™ (pemigatinib), Palforzia™ (peanut allergy powder), Tabrecta™ (capmatinib), Retevmo™ (selpercatinib), Sunosi™ (solriamfetol), Wakix® (pitolisant) and Xyrem® (sodium oxybate).
Preferred Drug List (PDL) therapeutic classes from the August 12, 2020 Drug Review Committee Meeting for the following:
Antidiabetic agents (oral, inhaled, injection and insulin), Antipsychotic long-acting injections, and PCSK9 inhibitors.
5/27/2020 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board April 15, 2020 meeting for the following:
Manual review criteria for: Brukinsa™, Tazverik™, Ayvakit™, Revlimid®, and Spravato®; Point-of-Sale criteria changes for: Lovaza® and Lysteda®; New Claim Edits: Leucovorin, Targeted Immunomodulators, and Gabapentin.
Preferred Drug List (PDL) therapeutic classes from the May 13, 2020 Drug Review Committee Meeting for the following:
Short-acting opioids, Allergic conjunctivitis ophthalmic agents, Ophthalmic antibiotics, Ophthalmic antibiotic/steroid combinations, Anti-inflammatory ophthalmic agents, Ophthalmic glaucoma agents, Topical corticosteroids
2/26/2020 The Arkansas Medicaid Pharmacy Program Provider Memorandum dated February 26, 2020 HAS BEEN UPDATED. Please see this most current Memo that provides clarification of AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board January 15, 2020 meeting for the following:
Manual review criteria for: Esbriet®, Ofev®, Temodar®, Nourianz™, Egaten®. Trikafta™, FEIBA, NovoSeven RT, Pretomanid, Nayzilam®, Oxbryta®; Point-of-Sale criteria changes for: Entresto®, Sensipar®, Procrit®, Epogen® and medications for treating asthma (oral ICS and ICS-LABA).
Preferred Drug List (PDL) therapeutic classes from the February 12, 2020 Drug Review Committee Meeting for the following:
Long-acting opioids, Androgenic agents (topical and injectable), Antifungals (topical), Bladder Relaxants, Bronchodilators (Long-Acting Beta Agonists and Short-Acting Beta Agonists), Glucagon Agents, Intranasal Rhinitis Agents and Anti-inflammatory/Immunomodulator Ophthalmic Agents.
The criteria listed in the Memo for the following was updated on March 16, 2020:
1. Age edits for Advair Diskus, Dulera and Symbicort have been updated.
2. Entresto’s CHF diagnosis look-back has been changed from 2 years to 3 years.
3. Clarification of criteria for ICS-LABA preferred agents (Advair Diskus, Dulera and Symbicort) has been updated to decrease any confusion.
12/31/2019 Medication Assisted Treatment (Act 964):
Pursuant to Act 964, Medicaid is removing the prior authorization requirement on the following drugs used to treat opioid use disorder: Suboxone® Film (buprenorphine/naloxone sublingual film) and Buprenorphine sublingual tablets.
11/27/2019 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board October 16, 2019 meeting for the following:
Manual review criteria for: HEMLIBRA® (emicizumab) injections; CABLIVI®(caplacizumab-yhdp) injections; PIGRAY®(alpelisib) tablets; XPOVIO™(selinexor) tablets; IRESSA®(gefitinib) tablets; NUBEQA™ (darolutamide) tablets; TURALIO™ (pexidartinib) capsules; INREBIC®(fedratinib) capsules; NUCALA® (mepolizumab) injection; BAGSIMI™ (glucagon) powder; ROZLYTREK™(enrectinib); Update on current PA criteria on: INGREZZA® (valbenazine) capsules; AUSTEDO®(deutetrabenazine) tablets; TRUVADA®(emtricitabine and tenofovir disoproxil fumarate); TOBACCO CESSATION PRODUCT UPDATE
Preferred Drug List (PDL) Drugs from the November 13, 2019 Drug Review Committee Meeting for the following:
Triptans, COPD agents, Inhaled Glucocorticoids, MS Agents, Oral/Topical NSAIDs, Oral/Inhaled/Injectable PAH agents; Opiate Dependence Treatments (injectable only).
10/28/2019 Arkansas Medicaid Pharmacy Program updates and information:
This memorandum is to provide updates from the Arkansas Medicaid Pharmacy Program. These updates include clarification of Ranexa status, preferred inhaled antibiotics, status of opium tincture and hyoscyamine, and information on the upcoming changes with Medication-Assisted Treatment for Opioid Use Disorder
8/28/2019 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board July 17, 2019 meeting for the following:
Manual review criteria for NUZYRA® (omadacycline) for injection and oral tablets; ABILIFY MYCITE® (aripiprazole) tablets; FIRDAPSE®/RUZURGI (amifampridine) tablets; BALVERSA™ (erdafitinib) tablets; ALPHA-1 PROTEINASE INHIBITORS; HEPATITIS C VIRUS TREATMENT IN PEDIATRICS; TIBSOVO® (ivosidenib) tablets; VYNDAQEL®/VYNDAMAX™ (tafamidis meglumine/tafamidis) capsules; TARCEVA® (erlotinib) tablets AND EVENITY™ (romosozumab-aqqg) injection. Update on current criteria for EMFLAZA® (deflazacort) tablets; PROTON PUMP INHIBITORS; OSTEOPOROSIS TREATMENT AND NEW MEDICATION-ASSISTED TREATMENT FORMS.
Preferred Drug List (PDL) Drugs from the August 14, 2019 Drug Review Committee Meeting for the following:
Inhaled antibiotics; CGRP-receptor blockers for migraine; bone resorption suppression and related agents; growth hormones; otic anti-infectives and anesthetics; otic antibiotics, pancreatic enzymes and head lice agents
5/17/2019 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board April 17, 2019 meeting for the following:
Manual review criteria for DUPIXENT® (dupilumab); DAURISMO™ (glasdegib); XOSPATA® (gilteritinib); VITRAKVI® (larotrectinib); SYMPAZANTM (clobazam); TALZENNA™ (talazoparib); TEGSEDI™ (inotersen); INBRIJA™ (levodopa inhalation); ARIKAYCE® (amikacin liposome); Heredity Angioedema Therapy. POS criteria for Oral typical and atypical antipsychotic agents for adult age 18 years and older; PRIMAQUINE tablets; KRINTAFEL (tafenoquine).
Preferred Drug List (PDL) Drugs from the May 8, 2019 Drug Review Committee Meeting for the following:
Oral antipsychotics and proton pump inhibitors
2/14/2019 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board January 16, 2019 meeting for the following:
Manual review criteria for JAKAFI® (ruxolitinib); New clinical point of sale criteria: ZORTRESS® (everolimus); ZORTRESS® (everolimus); New drugs manual review criteria: XOFLUZA™ (baloxavir marboxil); RYCLORA™ (dexchlorpheniramine maleate); COPIKTRA™ (duvelisib); VIZIMPRO® (dacomitinib; EPIDIOLEX® ORAL SOLUTION; NOCDURNA® (desmopressin acetate tablet); LORBRENA® (Lorlatinib); GALAFOLD™ (migalastat); ABILIFY MYCITE® (aripiprazole) Tablet
Preferred Drug List (PDL) Drugs from the February 13, 2019 Drug Review Committee Meeting for the following:
Long-Acting Opioids
11/30/2018 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board OCTOBER 17, 2018 meeting for the following:
Manual review criteria for asthma for non-preferred drug Spiriva Respimat; New drugs manual review criteria: ORILISSA™ (elagolix); DOPTELET® (avatrombopag); MULPLETA® (lusutrombopag); SIKLOS® (hydroxyurea); MEKTOVI® (binimetinib); BRAFTOVI™ (encorafenib); LOKELMA™ (sodium zirconium cyclosilicate)
Preferred Drug List (PDL) Drugs from the NOVEMBER 14, 2018 Drug Review Committee Meeting for the following:
Beta Adrenergic Blocking agents, Bowel Prep Agents, 2nd Generation Antidepressants
8/30/2018 AR Medicaid Prior Authorization Edits Approved at the AR Medicaid DUR Board JULY 18, 2018 meeting for the following:
Criteria Changes For MAT Drugs, EMFLAZA™ (deflazacort), mycophenolate, Codeine C&C products, Opioid & Benzodiazepine Drug Criteria Regarding Non-Fatal Poisoning Diagnoses; New criteria for AIMOVIG™ (erenumab-aooe), JYNARQUE™ (tolvaptan), LUCEMYRA™ (lofexidine), PALNZIQ™ (pegvaliase-pqpz), SYMDEKO™ (tezacaftor and ivacaftor)
New Preferred Drug List (PDL) Drugs Approved at the AUGUST 8, 2018 Drug Review Committee Meeting include the following:
Drugs for Treating Opioid Use Disorder (OUD); cystine-depleting agents.
5/31/2018 AR Medicaid PA edits approved at the AR Medicaid DUR Board APRIL 18, 2018 meeting for the following:
Changes to prescriber requirements for MAT drugs, MME/day changes for opioids, Refill Too Soon Accumulation Limits, Diphenoxylate/Atropine tablets, ERLEADA™, HUMIRA®, NARCAN® NASAL SPRAY, naloxone vial and pre-filled syringe, NERLYNX™, SOLOSEC™
NEW PDL DRUG CATEGORIES approved at the MAY 9, 2018 PDL meeting:
C-III stimulants, phosphate binders for CKD, ESA agents, colony stimulating factors, platelet aggregation inhibitors, lipotropic
3/1/2018 AR Medicaid PA edits approved at the AR Medicaid DUR Board JANUARY 17, 2018 meeting for BAXDELA, BENZNIDAZOLE, CALQUENCE, ENDARI, HEMLIBRA, LUPRON DEPOT-PED, SYNAREL, NOXAFIL SUSP., PREVYMIS, TIZANIDINE, BACLOFEN, VABOMERE, VERZENIO, XARELTO;
PDL changes approved by the PDL Drug Review Committee meeting FEBRUARY 14, 2018 for Anticoagulants, Antihistamines, Antihyperuricemics, Chronic GI Motility Agents, HCV, ICS.
1/31/2018 Clarification of New Opioid Criteria Rules
Arkansas Medicaid Pharmacy Program is sending out an amendment to the November 22, 2017 memorandum corresponding to the October 18th, 2017 DUR Board meeting. This is to clarify the revision to the criteria for Medicaid beneficiaries who are “NEW STARTS TO OPIOID THERAPY”.
11/22/2017 AR Medicaid PA edits approved at the AR Medicaid DUR Board OCTOBER 18, 2017 meeting and PDL changes approved by the PDL Drug Review Committee meeting NOVEMBER 8, 2017:
UPDATE OF THE AR MEDICAID PREFERRED DRUG LIST (PDL) DRUG CATEGORIES: ACEI Inhibitors, Renin Inhibitors, and Combination Products; Angiotensin II Receptor Blockers (ARB) and ARB Combination Products; ADD/ADHD Medications; INSULINS; Targeted Immune Modulators (TIMS); Self-Injected Epinephrine;
CHANGES TO EXISTING CRITERIA, INCLUDING POINT OF SALE (POS) CRITERIA, MANUAL REVIEW PA CRITERIA, OR CLAIM EDITS,: MME daily limits; KALYDECO® (ivacaftor); PULMICORT (budesonide) RESPULES®; MONTELUKAST; ENBREL® (etanercept); HUMIRA® (adalimumab); REVISED POS Criteria for Medicaid Beneficiaries Who Are “New Starts To Opioid Therapy”; Preferred and Non-Preferred Pulmonary Arterial Hypertension (PAH) Drugs; Refill Too Soon Early Refill Accumulation Limit;
NEW CLINICAL POS EDITS WITH OR WITHOUT ADDITIONAL CLAIM EDITS: Edits to Improve the Safe Prescribing of Opioids and Benzodiazepines after Non-Fatal Poisoning or Overdose; CAROSPIR® (Spironolactone 25mg/5mL) Suspension; ACYCLOVIR Oral Suspension 200 mg/ 5 mL;
NEW MANUAL REVIEW EDITS WITH OR WITHOUT ADDITIONAL CLAIM EDITS: ZYKADIA® (ceritinib) Capsule 150 mg; INGREZZA™ (valbenazine) Capsule 40 mg; AUSTEDO® (deutetrabenazine) Tablet 6 mg, 9 mg, 12 mg; XERMELO™ (telotristat ethyl) 250 mg Tablet; 4) MYDAYIS™ (dextroamphetamine sulfate, dextroamphetamine saccharate, amphetamine aspartate monohydrate, and amphetamine sulfate capsule, extended release) 12.5 mg, 25 mg, 37.5 mg, 50 mg; IDHIFA® (enasidenib mesylate) tablet, film coated 50 mg,100 mg.
9/1/2017 AR Medicaid PA edits approved at the AR Medicaid DUR Board JULY 19, 2017 meeting and PDL changes approved by the PDL Drug Review Committee meeting August 9, 2017:
ADDITIONS TO THE AR MEDICAID PREFERRED DRUG LIST (PDL):Please see the PDL list below for specific Preferred-status and Non-preferred status agents in the following categories that are being added to the PDL for Long-acting injectable antipsychotic drugs and Anti-diabetes drugs in the following categories:TZDs, SGLT2 Inhibitors, DPP-4 Enzyme Inhibitors, GLP-1 Receptor Agonists, Meglitinides.
CHANGES TO EXISTING PA CRITERIA EDITS:ESBRIET® (pirfenidone)tablet/capsule; OFEV® (nintedanib)capsule; LYRICA® (pregabalin) capsuleand oral solution; BUTALBITAL combination products that do not contain codeine; LINZESS™ (linaclotide) capsule; RELISTOR® (methylnaltrexone) SQ and oral tablet, MOVANTIK® (naloxegol) tablet, AMITIZA® (lubiprostone) capsule, TRULANCE™ (plecanatide) tablet;
CHANGES TO EXISTING CLAIM EDITS OR NEW CLAIM EDITS, INCLUDING AGE EDITS, DOSE-OP, DAILY DOSE/QUANTITY EDITS, CUMULATIVE QUANTITY EDIT, And ACCUMULATION EDITS:CORTISPORIN® (neomycin and polymyxin b sulfates, bacitracin zinc, and hydrocortisone) ointment and cream; OPHTHALMIC ANTIBIOTIC drops; OPHTHALMIC ANTIBIOTIC-STEROID drops;OPHTHALMIC drops for treating GLAUCOMA; All OPIOID-CONTAININGORAL LIQUIDS; CODEINE tablets, CODEINE-ACETAMINOPHEN TABLETS and oral solution, CODEINE-GUAIFENESIN COUGH/COLD PREPARATIONS, TRAMADOL IR tablets, TRAMADOL-ACETAMINOPHEN tablets, and TRAMADOLER tablets and capsules;
NEW CLINICAL POSEDITS WITH OR WITHOUT ADDITIONAL CLAIM EDITS: CYSTADANE® (betaine) powder for oral solution;
NEW MANUAL REVIEW EDITS WITH OR WITHOUT ADDITIONAL CLAIM EDITS:RHOFADE™ (oxymetazoline) topical cream; ZEJULA™ (niraparib) capsule; 3)DUPIXENT® (dupilumab)SQ Injection; ZOLINZA® (vorinostat) capsule; 5)CAPRELSA® (vandetanib) tablet; ALUNBRIG™ (brigatinib) tablet; RYDAPT® (midostaurin) capsule; KISQALI® (ribociclib) tablet and KISQALI® FEMARA® (letrozole) CO-PACK;
REMINDERS:MME changes; Manual Review PA Requests;
CLARIFICATION:KALYDECO®(ivacaftor)
5/30/2017 AR Medicaid PA edits approved at the AR Medicaid DUR Board APRIL 19, 2017 meeting and PDL changes approved by the PDL Drug Review Committee meeting MAY 10, 2017:
ADDITIONS TO THE AR MEDICAID PREFERRED DRUG LIST (PDL): Please see the PDL list below for specific Preferred-status and Non-preferred status agents in the following categories that are being added to the PDL: topical corticosteroid agents; drugs for treating glaucoma; ophthalmic antibiotic agents; ophthalmic antibiotic-steroid combination agents; short-acting narcotic analgesic agents.
CHANGES TO EXISTING PA CRITERIA OR EXISTING CLAIM EDITS: Maximum Daily Morphine Milligram Equivalent (MME) edit decreased; Topical Corticosteroid quantity edits revised; preferred PPI (omeprazole 20 mg capsule, pantoprazole 20 mg and 40 mg tablet) revised approval criteria; Orkambi® (lumacaftor/ivacaftor) tablet continuation criteria clarified.
NEW CLINICAL EDITS THROUGH MANUAL REVIEW PRIOR APPROVAL (PA) PROCESS: Rubraca™ (rucaparib) tablet; Impavido® (miltefosine) capsule; Ryvent™ (carbinoxamine maleate) tablet; Migergot® (ergotamine/caffeine) suppository; Ilaris® (canakinumab) injection; Emflaza™ (deflazacort) tablet and suspension; Eucrisa™ (crisaborole) ointment.
NEW CLAIM EDITS, INCLUDING DOSE-OP, DAILY DOSE/QUANTITY EDITS, CUMULATIVE QUANTITY EDIT, And ACCUMULATION EDITS: Quantity edits for Lidocaine 5% Ointment; Biltricide® (praziquantel) tablet; Albenza® (albendazole) tablet; Cyclobenzaprine tablets;
2/20/2017 AR Medicaid PA edits approved at the AR Medicaid DUR Board JANUARY 18, 2017 meeting and PDL changes approved by the PDL Drug Review Committee meeting FEBRUARY 1, 2017:
ADDITIONS TO THE AR MEDICAID PREFERRED DRUG LIST (PDL): Please see the list below for the changes or additions to Preferred-status agents in the following categories: buprenorphine-containing agents for treating opiate dependence; Pulmonary Arterial Hypertension (PAH) Agents; Topical Pediculicide Agents for Treating Head Lice Infestations; Topical Antifungal Agents.
CHANGES TO EXISTING POINT OF SALE (POS) PRIOR AUTHORIZATION (PA) CRITERIA OR NEW POS PA CRITERIA OR EDITS: COPD drug criteria revised; Opioid MME Reduction to 250 MME/day; Enbrel® (etanercept) injection; Methadone Oral Solution for NAS; Sensipar® (cinacalcet) tablet;
CHANGES TO EXISTING MANUAL REVIEW PA CRITERIA OR NEW MANUAL REVIEW PA CRITERIA: Xolair® (omalizumab) injection; Humira® (adalimumab) injection; Cabometyx® (carbozantinib) tablet; Zinplava™ (bezlotoxumab) IV infusion; Orkambi® (lumacaftor/ivacaftor) tablet
12/14/2016 AR Medicaid PA edits approved at the AR Medicaid DUR Board October 19, 2016 meeting and PDL changes approved by the PDL Committee Nov 9, 2016:
ADDITIONS TO THE AR MEDICAID PREFERRED DRUG LIST (PDL): Please see the list below for the changes or additions to Preferred-status agents in the following categories: Overactive Bladder, Self-injected Epinephrine, Inhaled Short-Acting Beta Agonists, COPD Agents (Inhaled Long-Acting Beta Agonists, Inhaled Short-Acting Anticholinergics, Inhaled Long-Acting Anticholinergics, and PDE-4 Inhibitor), Inhaled Corticosteroids, Inhaled Corticosteroid / Bronchodilator Combination Agents, and Multiple Sclerosis Agents.
CHANGES TO EXISTING POINT OF SALE PRIOR AUTHORIZATION (PA) CRITERIA OR EDITS: Second Generation Antidepressants, Trazodone, and Tricyclic Antidepressants prescribed to Children ≤ 3 years of age; Metaproterenol syrup10 mg/5 ml, 10 mg, 20 mg tablet; Terbutaline tablets and vials for injection; Topical Fluorouracil Agents, Potassium Chloride Oral Liquid and Effervescent tablets;
NEW AND REVISED CLINICAL EDITS THROUGH THE MANUAL REVIEW PA PROCESS: Corlanor® (ivabradine HCl); Ocaliva™ (obeticholic acid); Synera® (lidocaine/tetracaine) Patch; Dibenzyline® (phenoxybenzamine); Zurampic® (lesinurad) tablet; Tasigna® (nilotinib) capsule; Xiidra™ (lifitegrast) ophthalmic solution; Tykerb® (lapatinib) tablet; Spritam® (levetiracetam) tablet for suspension.
8/29/2016 AR Medicaid PA edits approved at the AR Medicaid DUR Board JULY 20, 2016 meeting:
ADDITIONS TO THE AR MEDICAID PREFERRED DRUG LIST (PDL): Preferred status added to the following drugs: OTIC: Ciprodex® otic, neomycin/polymyxin HC otic, ciprofloxacin otic, acetic acid 2% otic, acetic acid HC otic; PANCREATIC ENZYMES: CREON®, ZENPEP®; CF INHALED ANTIBIOTICS: BETHKIS®, KITABIS™; GROWTH HORMONES: GENOTROPIN®; HCV TREATMENT: ZEPATIER™, EPCLUSA®, ribavirin 200 mg tablets and capsules;
CHANGES TO EXISTING POINT OF SALE PRIOR AUTHORIZATION (PA) CRITERIA OR EDITS: Total daily dose 300 Morphine Milligram Equivalents (MME) for all short-acting opioid drugs, long-acting opioid drugs, or combination of both, for chronic pain patients;
NEW AND REVISED CLINICAL EDITS THROUGH THE MANUAL REVIEW PA PROCESS: NINLARO® (ixazomib); ENTRESTO™ (sacubitril and valsartan); VRAYLAR™ (cariprazine); VENCLEXTA™ (venetoclax); NUPLAZID™ (pimavanserin); SERNIVO™ (betamethasone dipropionate); EMVERM™ (mebendazole); BRIVIACT® (brivaracetam);
CLAIM EDITS, INCLUDING DOSE-OP, DAILY DOSE/QUANTITY EDITS, CUMULATIVE QUANTITY EDIT, And ACCUMULATION EDITS: loperamide 2 mg capsule
6/8/2016 AR Medicaid PA edits approved at the AR Medicaid DUR Board April 20, 2016 meeting:
CHANGES TO EXISTING POINT OF SALE PRIOR AUTHORIZATION (PA) CRITERIA OR EDITS: OPIOID CEILING DOSE OF MORPHINE MILLIGRAM EQUIVALENTS (MME) FOR OPIOID DRUGS; C-II STIMULANTS and C-III STIMULANTS (modafinil or armodafinil ) for non-ADD/ADHD diagnoses; ANTIPSYCHOTIC AGENTS FOR CHILDREN less than 18 years of age; GROWTH HORMONES (somatropin); ANADROL®-50 (oxymetholone);
NEW AND REVISED CLINICAL EDITS THROUGH THE MANUAL REVIEW PA PROCESS: HCV Therapies: ZEPATIER™ (elbasvir and grazoprevir), HARVONI® (ledipasvir and sofosbuvir); VIEKIRA PAK™ (ombitasvir, paritaprevir, and ritonavir tablets and dasabuvir tablets), DAKLINZA™ (daclatasvir), SOVALDI® (sofosbuvir); TECHNIVIE™ (ombitasvir and paritaprevir and ritonavir); KALYDECO® (ivacaftor); ORKAMBI™ (lumacaftor/ivacaftor); NARCAN® (naloxone) NASAL Spray; VIBERZI™ (eluxadoline); LOTRONEX® (alosetron); ALECENSA® (alectinib); UPTRAVI® (selexipag); LANOXIN® (digoxin); STRENSIQ™ (asfotase alfa); CORLANOR® (ivabradine HCl); TRESIBA® (insulin degludec injection) LA INSULIN PEN; GLEEVEC® (imatinib) 400 mg;
CLAIM EDITS, INCLUDING DOSE-OP, DAILY DOSE/QUANTITY EDITS, CUMULATIVE QUANTITY EDIT, And ACCUMULATION EDITS: Select Cough and Cold Products containing Codeine
3/16/2016 AR Medicaid PA edits approved at the AR Medicaid DUR Board January 20, 2016 meeting:
Changes To Existing Prior Authorization (PA) Criteria Or Edits: CIPRODEX® OTIC SUSPENSION changed to NO PA; generic OFLOXACIN otic drops will require Manual PA; Long-Acting Or Depot Formulation Antipsychotic Injectable Agents, including ABILIFY® MAINTENA™ (aripiprazole), ARISTADA™ (aripiprazole lauroxil), IVEGA SUSTENNA® (paliperidone palmitate), RISPERDAL CONSTA® (risperidone), ZYPREXA® RELPREVV™ (olanzapine pamoate), haloperidol decanoate inj., fluphenazine decanoate injection; All SHORT-ACTING OPIOID AGENTS in tablet or capsule form;
Clinical edits through the Manual Review PA Process: HCV Treatment HARVONI® (ledipasvir and sofosbuvir); HUMIRA® (adalimumab) injection when used for treating HS; ODOMZO® (sonidegib) 200 mg capsules; LONSURF® (trifluridine and tipiracil) tablets 20 mg/8.19 mg and 15 mg/6.14 mg; GLEOSTINE™ (lomustine) capsules 100 mg, 40 mg, 10 mg, 5 mg; TAGRISSO™ (osimertinib) tablets , 80 mg, 40 mg; COTELLIC™ (cobimetinib) tablets 20 mg; VELTASSA™ (patiromer) powder for oral suspension.
8/14/2015 AR Medicaid DUR Board edits approved at the July 15, 2015 meeting:
Changes To Existing Prior Authorization (PA) Criteria Or Edits: Viekira Pak™ (dasabuvir and ombitasvir and paritaprevir and ritonavir); Oral anticoagulant drugs; Protopic® (tacrolimus) ointment, Elidel® (pimecromlimus) cream, Dovonex® (calcipotriene) cream; Evista® (raloxifene hydrochloride) tablet; Regranex® (becaplemin) gel; Movantik™ (naloxegol) tablet; Constipation drugs including Linzess® (linaclotide), Amitiza® (lubiprostone), Movantik™ (naloxegol), and Relistor® (methylnaltrexone bromide); Xarelto® (rivaroxaban) 10 mg; Long-acting opioid agents;
Clinical edits through the Manual Review PA Process: Cholbam™ (cholic acid); Natpara® (parathyroid hormone); Sandostatin® (octreotide acetate) LAR Depot Injection; Invega Trinza™ (paliperidone palmitate) injection; Namzaric™ (memantine/donepezil) capsule;
Point-of-Sale (POS) Clinical Edits with or without Claim Edits: Avycaz™ (ceftazidime-avibactam) inj.; Cresemba® (isavuconazonium sulfate) capsule and vial.
6/15/2015 AR Board edits approved at the April 15, 2015 meeting:
Changes To Existing Prior Authorization (PA) Criteria Or Edits: All Tramadol products; Clarifying look-back period for NPO/”swallow criteria”; Oral Anticoagulants: warfarin, ELIQUIS® (apixaban), PRADAXA® (dabigatran etexilate mesylate), XARELTO® (Rivaroxaban), and XARELTO® Starter Pack, SAVAYSA™ (edoxaban tosylate); SL Allergen Extracts: Grastek®, Ragwitek™; Amitiza® (lubiprostone), Linzess™ (linaclotide); Opioid–Induced Constipation (OIC): Relistor® (methylnaltrexone bromide) injection;
Clinical edits through the Manual Review PA Process: Synribo® (omacetaxine mepesuccinate) 3.5 mg/ml vial for SQ administration; Esbriet® (pirfenidone) 267 mg capsule; Ofev® (nintedanib) capsule, 100 mg and 150 mg; Thiola® (tiopronin) tablet 100 mg; Zelapa® (selegiline) 1.25 mg ODT tablet;
AEVCS edits, including Dose-op edits, Cumulative Quantity, Daily Dose edits, Age edits, or Gender edits: Mesalamine enema 4 gm/60 ml; Sucralfate 1 gm/10 ml suspension.
3/12/2015 AR Medicaid DUR Board edits approved at the January 21, 2015 meeting:
Changes To Existing Prior Authorization (PA) Criteria Or Edits: Albuterol IR 4mg tablets; Myalept 11.3 (5mg/ml) (metreleptin) vial; New HCV therapies (Sovaldi®, Harvoni®, and Viekira Pak®); Daytrana® (methylphenidate transdermal system) 10 mg, 15 mg, 20 mg, and 30 mg patch;
Clinical edits through the Manual Review PA Process: Synribo® (omacetaxine mepesuccinate) 3.5 mg/ml vial for SQ administration; Esbriet® (pirfenidone) 267 mg capsule; Ofev® (nintedanib) capsule, 100 mg and 150 mg; Thiola® (tiopronin) tablet 100 mg; Zelapa® (selegiline) 1.25 mg ODT tablet;
AEVCS edits, including Dose-op edits, Cumulative Quantity, Daily Dose edits, Age edits, or Gender edits: Mesalamine enema 4 gm/60 ml; Sucralfate 1 gm/10 ml suspension;
2/10/2015 New Medicaid Pharmacy Vendor
1/26/2015 New Medicaid Pharmacy Vendor
12/19/2014 New Medicaid Pharmacy Vendor
11/26/2014 AR Medicaid DUR Board Edits Approved at the October 15, 2014 Meeting:
Changes to Existing Prior Authorization (PA) Criteria or Edits; Clinical Edits through the Manual Review PA Process; AEVCS Edits, including Dose-Op Edits, Cumulative Quantity, Daily Dose Edits, Age Edits, or Gender Edits
9/15/2014 New Medicaid Pharmacy Vendor
8/18/2014 AR Medicaid DUR Board edits approved at the July 16, 2014 meeting:
Changes To Existing Prior Authorization (PA) Criteria Or Edits:
Synagis® (palivizumab); Xolair® (omalizumab) injection; Denavir® (penciclovir) 1% 5 gm cream; Clinical edits through the Manual Review PA Process: Lazanda® (fentanyl) nasal spray; Ragwitek™ (short Ragweed Pollen Allergen Extract); Grastek® (Timothy Grass Pollen Allergen Extract); Myalept™ (metreleptin) injection; Hetlioz™ (tasimelteon) capsule; Orfadin® (nitisinone) capsule; Oxsoralen-Ultra® (methoxsalen) capsule; 8-MOP® (methoxsalen) capsule; Zykadia™ (ceritinib) capsule; Zontivity™ (vorapaxar) tablet; Sylvant™ (siltuximab); Evzio™ (naloxone) auto-injector; Sitavig® (acyclovir) buccal tablet
5/21/2014 AR Medicaid DUR Board edits approved at the April 16, 2014 meeting:
Changes To Existing Prior Authorization (PA) Criteria Or Edits: CII stimulants; Cuvposa® (glycopyrrolate) oral solution; Noxafil® (posaconazole) oral suspension; Proton Pump Inhibitors (PPI)
Clinical edits through the Manual Review PA Process: Noxafil® (posaconazole) DR tablet and Noxafil® (posaconazole) inj.;glycopyrrolate 0.2 mg/ml vials and Cuvposa® (glycopyrrolate) oral solution; Sovaldi® (sofosbuvir) tablet; Olysio® (simeprevir) capsule; Otrexup® (methotrexate) auto injector; clonidine HCl PF vials; Aptiom® (eslicarbazepine acetate) tablet; Zohydro® (hydrocodone) ER capsule; Fycompa® (perampanel) tablet; Fosrenol® chew tablets; Velphoro® chew tablet; Renvela® powder packets
Clinical edits added through point-of-sale (POS) edit system: Lupaneta® (leuprolide/norethindrone acet) kit 3.5-5 mg 1 month inj. and 11.25-5 mg 3 month inj. AEVCS edits (Dose-op edits, Cumulative Quantity, Daily Dose edits, Age edits, or Gender edits): Afinitor® (everolimus) disperz tablets; Vimpat® (lacosamide) tablets
2/12/2014 AR Medicaid DUR Board edits approved at the Jan. 15, 2014 meeting:
Clinical edits added through point-of-sale (POS) edit system: Long-acting formulations of oral solid dosage forms for which exists an IR formulation; Insulin pens for which exists a multidose vial of the same formulation
Clinical edits through the Manual Review PA Process: Adempas® tablets; Opsumit® tablet; Glycate® tablet; Procysbi® capsules; tobramycin inhalation solution; Bethkis® inhalation solution; Valchlor® topical gel; unit dose liquids for which bulk liquids exist with MAC pricing; Imbruvica® capsule; albuterol ER tablets and syrup; Lamictal® disper tablets; Lamictal® or lamotrigine start kits
AEVCS edits (Dose-op edits, Cumulative Quantity, Daily Dose edits, Age edits, or Gender edits): promethazine suppositories; Neupogen® injection; Neulasta® injection; Emsam® patches; Ranexa® ER tablets; Afinitor® disperz tablets; Vimpat® tablets
11/8/2013 Arkansas Medicaid DUR Board edits approved at the October 9, 2013 meeting:
Clinical edits added through point-of-sale (POS) edit system: CellCept® (mycophenolate mofetil);
Clinical edits through the Manual Review PA Process: ASTAGRAF XL™ (tacrolimus); TOBI® Podhaler™ (tobramycin inhalation powder); SIRTURO™ (bedaquiline fumarate); NYMALIZE™ (nimodipine); Trokendi XR™ (topiramate); CYSTARAN™ (cysteamine HCl) ophthalmic drops; GILOTRIF™ (afatinib dimaleate); ZYTIGA® (abiraterone acetate);
AEVCS edits (Dose-op edits, Cumulative Quantity, Daily Dose edits, Age edits, or Gender edits): Butalbital combination pain medications (butalbital/APAP; butalbital/ASA/Caffeine)
10/21/2013 NCPDP Field Requirement
8/5/2013 AR Medicaid DUR Board edits approved at the July 17, 2013 meeting:
Changes to existing PA Criteria or Edits: desonide 0.05% cream; Revised age ranges and max daily doses for oral 2nd generation ("Atypical") antipsychotic agents for children;
Clinical edits added through point-of-sale (POS) edit system: Dose edits for oral 1st generation ("Typical") antipsychotic agents for children; dose edits & manual review for Fanapt®, Latuda®, Saphris® for use in children; perphenazine/amitriptyline tablet use in children; Risperdal® Consta®; Invega® Sustenna®; 1st & 2nd generation long-acting and depot forms of injectable antipsychotic agents; Lexiva® tablets and oral suspension; complete doseoptimization chart for oral antipsychotic agents;
Clinical edits through the Manual Review PA Process: Ridaura® 3 mg capsule; Osphena™ tablet; Signifor® inj.; BiDil® tablet; Diclegis® tablet; Vecamyl™ tablet; Lovaza® capsule, penicillamine; Syprine® capsule; Tafinlar® capsule; Mekinist™ tablet; Glycophos® vial;
AEVCS edits, including Dose-op edits, Cumulative Quantity, Daily Dose edits, Age edits, or Gender edits: Alzheimer's Disease agents; naltrexone 50 mg tablet; Viramune® tablets and oral suspension and Viramune® XR; Tikosyn® tablets
6/6/2013 AR Medicaid DUR Board edits approved at the April 17, 2013 meeting:
Changes to existing PA Criteria or Edits: Corticosteroid PA list updated; Accumulation quantity limit on short acting opioids
Clinical edits through the Manual Review PA Process: Acthar® (corticotropin) HP Gel Inj; Ravicti™(glycerol phenylbutyrate) liquid 1.1 gm/ml; Gattex® (teduglutide [rDNA origin]) 5 mg vial; Vascepa® (icosapent ethyl) 1 gm capsule; Juxtapid™ (lomitapide mesylate) 5 mg, 10 mg, 20 mg capsule; Kynamro™ (mipomersen sodium) 200 mg syringe; Migranal® NS (dihydroergotamine mesylate) 4 mg/ml; Pomalyst® (pomalidomide) 1 mg, 2 mg, 3 mg, 4 mg capsules; Cometriq™ (cabozantinib) 20 mg, 60 mg, 80 mg, 100mg, 140 mg tablets; Promacta® (eltrombopag) 12.5 mg, 25 mg, 50 mg, 75 mg, 100 mg tablets; Fulyzaq™ (crofelemer) 125 mg delayed release tablet; Iclusig™ (ponatinib) 15 mg, 45 mg tablet; Giazo™ (balsalazide disodium) 1.1 gm tablet
Clinical edits added through point-of-sale (POS) edit system: Eliquis® (apixaban) 2.5 mg, 5 mg tablet; Uceris™ (budesonide) extended release 9 mg capsule; Entocort® (budesonide) EC 3 mg capsule; 1st and 2nd generation long-acting injectable antipsychotic agents in children
AEVCS edits, including Dose-op edits, Cumulative Quantity and Daily Dose edits: Santyl® ointment 30 gm tube; Mirapex® ER tablet; Requip® XL tablet
2/8/2013 AR Medicaid DUR Board edits approved at the Jan. 16, 2013 meeting:
Changes to existing PA Criteria or Edits: LTC recipients will be included in benzodiazepine accumulation quantity edit; clarithromycin XL criteria removed; Clinical edits through the Manual Review PA Process: Bosulif® (bosutinib) 100 mg and 500 mg tablets; Stivarga® (regorafenib) 40 mg tablet; Linzess® (linacoltide) 145 mg and 290 mg capsules; Onmel® (itraconazole) 200 mg tablet; Soltamox® (tamoxifen) 10 mg/5 ml oral solution;
Clinical edits added or revised through point-of-sale (POS) edit system: Zovirax® cream, Zovirax® oint., Denavir® cream; Xarelto® 15 mg and 20 mg tablet; Restless Leg Syndrome (RLS) drug criteria;
AEVCS edits, including Dose-op edits, Cumulative Quantity and Daily Dose edits: Medications that are deemed "Exclusively Pediatric" indications; primadone 50 mg; Emergency Override reminder
11/19/2012 AR Medicaid DUR Board edits approved at the October 17, 2012 meeting:
Clinical edits through the Manual Review PA Process: Truvada® (tenofovir 300 mg/emtricitabine 200 mg) when used for PrEP; XTANDI® (enzalutamide) capsules; Rayos® DR (prednisone) tablets;
Clinical edits added or revised through point-of-sale (POS) edit system: COPD medications— Spiriva® HandiHaler® (tiotropium bromide inhalation powder) and Tudorza™ Pressair™ (aclidinium bromide inhalation powder); Lyrica® (pregabalin) 20 mg/ml oral solution;
AEVCS edits, including Dose-op edits, Cumulative Quantity and Daily Dose edits: Invega® ER tablets; Antidiabetic agents Reminders: Antipsychotic agents require POS approval criteria in children < 18 yrs of age that require metabolic lab tests every 6 months. (see page 5) Section 175 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended section 1860D- 2(e)(2)(A) of the Act to include Medicare Part D coverage of barbiturates "used in the treatment of epilepsy, cancer, or a chronic mental health disorder" and benzodiazepines.
8/30/2012 AR Medicaid DUR Board edits approved at the July 18, 2012 meeting:
Clinical edits through the Manual Review PA Process: New drugs to market; KCl 8 mEq and 10 mEq capsules, and 25 mEq packets; Korlym® (mifepristone) tablet; Votrient® (pazopanib) tablet; Afinitor® (everolimus) tablets;
Clinical edits added or revised through point-of-sale (POS) edit system: Xyrem® (sodium oxybate) 500mg/ml oral solution;
Quantity Edits: Zirgan® (ganciclovir ophthalmic gel) 0.15%; Tindamax® (tinidazole) tablets; short-acting oral opioid analgesics; topical antifungal agents; topical antiparasitic agents;
NSAIDS Reminder regarding antipsychotic agents and requirement of POS criteria for metabolic lab tests monitoring that began June 12, 2012 in children < 18 yrs. of age can be found on page 6.
8/1/2012 System Confirmation of (6) Month Prescription Allowance
6/5/2012 AR Medicaid DUR Board edits approved at the April 18, 2012 meeting:
Clinical edits through the Manual Review PA Process: Kalydeco® (ivacaftor) 150 mg tablet; COSOPT® PF (timolol maleate/dorzolamide HCl) preservative free; INLYTA® (axitinib) 5 mg and 1 mg tablets; SKLICE™ (ivermectin) 0.5% topical lotion; ERIVEDGE™ (vismodegib) 150 mg capsule; FERRIPROX® (DEFERIPRONE) 500 mg tablets; ARCALYST® (RILONACEPT) 220 mg injection; RECTIV® (nitroglycerine) OINTMENT 0.4% FOR INTRA-ANAL USE; Temazepam 7.5 mg and 22.5 mg capsules; KEFLEX® (cephalexin) 750 MG CAPSULE; TRAZODONE (OLEPTRO® ER 150 MG AND ER 300 MG; TRAZODONE 300 MG); PICATO® (INGENOL MEBUTATE) GEL 0.01% AND 0.05% FOR TOPICAL USE; ONFI® (clobazam) 5 mg, 10 mg, 20 mg tablets
Clinical edits added or revised through point-of-sale (POS) edit system: Finasteride 5 mg tablets Quantity Edits: Zyvox® (linezolid) Zyvox® for oral susp. 100 mg/5 ml; Meprobamate 200 mg and 400 mg tablets; EMLA® cream (lidocaine-prilocaine topical cream), 5 gm tube and 30 gm tube; Uloric® (febuxostat) 40 mg and 80 mg tablet
REMINDER OF PREVIOUS COMMUNICATIONS ON PAGES 5 & 6: Reminder regarding April 17, 2012 ADD/ADHD PDL changes and continuation criteria for the non-preferred C-II stimulant drugs; reminder regarding antipsychotic agents and requirement of POS criteria for metabolic monitoring beginning June 12, 2012 in children < 18 yrs. of age.
3/15/2012 AR Medicaid DUR Board edits approved at the January 18, 2012 meeting:
Clinical edits through Manual Review PA Process: Prolia® (denosumab) 60 mg/ml inj; Xalkori® (crizotinib) caps; Zelboraf™ (vemurafenib) tablet; levothyroxine vials; Vistide® (cidofovir) inj;
Clinical edits added or revised through point-of-sale (POS) edit system: Pradaxa® (dabigatran) tablets; Xarelto® (rivaroxaban) tablets; Singulair® (montelukast); Quantity Edits: Zyvox® (linezolid tablet and oral suspension; antihistamine nasal sprays; Jakafi® (ruxolitinib) tabs; Somavert® (pegvisomant) inj; Cancidas® (caspofungin) vials;
UPDATE ON PREVIOUS COMMUNICATIONS: Reminder regarding Antipsychotic drug use in children < 18 yrs of age; methylphenidate IR change in status on PDL.
2/12/2014 AR Medicaid DUR Board edits approved at the Jan. 15, 2014 meeting:
Clinical edits added through point-of-sale (POS) edit system: Long-acting formulations of oral solid dosage forms for which exists an IR formulation; Insulin pens for which exists a multidose vial of the same formulation
Clinical edits through the Manual Review PA Process: Adempas® tablets; Opsumit® tablet; Glycate® tablet; Procysbi® capsules; tobramycin inhalation solution; Bethkis® inhalation solution; Valchlor® topical gel; unit dose liquids for which bulk liquids exist with MAC pricing; Imbruvica® capsule; albuterol ER tablets and syrup; Lamictal® disper tablets; Lamictal® or lamotrigine start kits
AEVCS edits (Dose-op edits, Cumulative Quantity, Daily Dose edits, Age edits, or Gender edits): promethazine suppositories; Neupogen® injection; Neulasta® injection; Emsam® patches; Ranexa® ER tablets; Afinitor® disperz tablets; Vimpat® tablets
11/23/2011 AR Medicaid DUR Board edits approved at the October 19, 2011 meeting:
Clinical edits through Manual Review PA Process: Eurax® (crotamiton) cream and lotion; Ryzolt™ ER (tramadol ER) 100mg, 200mg and 300mg tablet; Conzip® ER (tramadol ER) 100mg, 200mg and 300mg capsule; Benign prostatic hypertrophy drugs; Mast Cell Stabilizer eye drops, Antihistamine eye drops and Mast Cell Stabilizer/Antihistamine combination eye drops;
Clinical edits added or revised through point-of-sale (POS) edit system: Daliresp® (roflumilast) 500mcg tablet; Dificid® (fidaxomicin) 200mg tablet; Lodosyn® (carbidopa) 25mg tablet; Comtan® (entacapone) 200mg tablet; Stalevo® (carbidopa; Quantity Edits: Nystatin Topical Powder; Arava® (leflunomide); Celexa® (citalopram); fluoride preparations, Epipen® (epinephrine) syringes.
8/31/2011 AR Medicaid DUR Board edits approved at the JULY 20, 2011 meeting:
Clinical edits through Manual Review PA Process added to: antipsychotic agents for children < 18 yrs; testosterone products; short-acting opioid analgesic pain medications; oral HCV protease inhibitor agents; Dexpak® and Zema-pak®; bowel prep kits; Opium Tincture, USP (Deodorized);
Point-of-sale (POS) edit system: antibiotic-steroid fixed dose combination ophthalmic drops; Zyclara® (imiquimod) cream; Sporanox® (itraconazole) oral solution; furantoin solution, mycophenolate mofetil susp; sucralfate susp.; Tamiflu® oral susp; desmopressin intranasal formulations; Zovirax® 2 gm cream;
Quantity Edits: Pristiq® 50 mg; antibiotic and antibiotic/steroid combination ophthalmic ointments; triamcinolone 0.1% paste; Vectical® ointment; Dovonex® cream and solution; Tazorac® cream and gel; Mepron® suspension; Sporanox® 100 mg capsules; Zemplar® capsules; chlorzoxazone tablet; Rilutek® tablet.
INCARCERATED MEDICAID RECIPIENTS: Medicaid Pharmacy Program is prohibited from paying for drug claims for Medicaid recipients who are incarcerated.
5/17/2011 AR Medicaid DUR Board edits approved at the APRIL 20, 2011 meeting:
Clinical edits through Manual Review PA Process added to: Zantac® (ranitidine) 25 mg Efferdose tablet, Nuedexta® (dextromethorphan Hbr/quinidine) capsules, Cinryze® (C1 esterase inhibitor [human]), Natroba® (spinosad) topical suspension, Lysteda® (tranexamic acid) tablets, Benlysta® (belimumab), Botox® (botulinum toxin type A) 100 units and 200 units (onabotulinumtoxina), and Cuvposa® (glycopyrrolate) 1mg/5ml oral solution;
Clinical edits added or revised through point-of-sale (POS) edit system: Daliresp® (roflumilast) 500mcg tablet. Solaraze® (diclofenac) 3% gel, Efudex® (fluorouracil) 2% or 5% solution, 5% cream, Ranitidine 15mg/ml syrup, and Lupron- DEPOT® (leuprolide acetate) injections (including Lupron- DEPOT® PED); Quantity Edits: Canasa® (mesalamine) 1000mg suppository, and Fanapt® (iloperidone) titration pack and tablets.
INCARCERATED MEDICAID RECIPIENTS: Medicaid Pharmacy Program is prohibited from paying for drug claims for Medicaid recipients who are incarcerated.
3/11/2011 AR Medicaid DUR Board edits approved at the JANUARY 19, 2011 meeting:
Clinical edits through Manual Review PA Process added to: Selzentry (maraviroc);Kuvan (sapropterin dihydrochloride); Azithromycin Powder Packets and ZMAX® (azithromycin) Adult-Ped 2 gm/60 ml suspension;
Clinical edits added or revised through point-of-sale (POS) edit system: Protopic® (tacrolimus) and Elidel® (pimecromlimus; Lamisil® (terfinafine) Granule Packet; Renvela® 0.8 gm Powder Packet; Injectable pain medications;
Cumulative Quantity Edits: Injectable pain medications; Benzonatate capsules; injectable antibiotic and antifungal drugs;
INCARCERATED MEDICAID RECIPIENTS: Medicaid Pharmacy Program is prohibited from paying for drug claims for Medicaid recipients who are incarcerated.
12/8/2010 AR Medicaid DUR Board edits approved at the OCTOBER 20, 2010 meeting:
Clinical edits through Manual Review PA Process added to: C-II stimulant use in ADULTS age 18 yrs and older; Suboxone® or Subutex® edits revised; Fenofibrate & Fenofibric Acid products; Millipred® (prednisolone) 5 mg tablets and tablet dose packs; CiproDex® Otic Susp (ciprofloxacin/dexamethasone), Cipro HC® Otic Susp (ciprofloxacin/HC), Trioxin® Otic susp (chloroxylenol/benzoc/HC), Cortisporin-TC® Ear susp (Neomy sulf/colist sul/HC/thonz), Cortamox® lotion (HC/pramoxine HCl/chloroxylenol), Coly-mycin S® Ear Drops (neomy sulf/colist sul/HC/thonz), and Acetasol HC ear drops;
Clinical edits added or revised through point-of-sale (POS) edit system: topical steroid agents; topical antifungal agents; Pulmozyme® (dornase alfa) inhalation solution; TOBI® (tobramycin) inhalation solution; Restasis® (cyclosporine) .05% Eye Emulsion, Lacrisert® (hydroxyproply cellulose) 5 mg eye insert; Vectical® (calcitriol) ointment, Tazorac® (tazarotene) gel/cream, Dovonex® (calcipotriene) cream; Protopic® (tacrolimus), Elidel® (pimecrolimus), Testosterone replacement products (Androgel® Androderm®, Testim®, testosterone injection); Valcyte® (valganciclovir) oral solution; topical products for treating rosacea; topical products for treating seborrheic dermatitis; Humira® (adalimumab) injection;
ICD9 code list used to identify COPD patients in Medicaid history for PA criteria revised;
Cumulative Quantity Edits: Drugs in the Medicaid system that currently have a daily dose limit will have a cumulative quantity edit added; Non-FDA approved drugs removed from coverage: topical Urea, Salicylic Acid, Urea/Salicylic Acid, and urea/lactic acid/salicylic acid, urea/hyaluronate sodium, urea/lactic acid/zinc undecylenate, salicylic acid/ammon lact/aloe, lactic acid products; topical sulfacetamide sodium products, and selenium sulfide 2.25% shampoo; FreshKote® Eye Drops
8/26/2010 AR Medicaid DUR Board edits approved at the JULY 21, 2010 meeting:
Clarification of PPI edits;
Clinical edits through POS SmartPA system added to: all benzodiazepines; Zyprexa® Relprevv™; Aldex® AN chew tablet; Rybix® ODT; Xifaxan® 200 mg and 550 mg tablets; Xolegel® 2% gel; Extina® 2% foam; Singulair®;
Clinical edits through manual review added to: Ampyra® tablet; Cayston® inhalation solution;
6/11/2010 AR Medicaid DUR Board edits approved at the APRIL 21, 2010 meeting:
Clinical edits added to: ARBs; acetic acid HC ear drops; non-preferred drug Maxalt MLT (rizatriptan); Osteoporosis drugs; Proton Pump Inhibitors; Orapred® (prednisolone sodium phosphate) ODT tablets; Trexall® (methotrexate); clarithromycin XL 500 mg tablet; Flagyl® (metronidazole) ER 750 mg tablet; topiramate sprinkle capsules 15 mg and 25 mg; Uloric® tablets; “Kits” and combination products containing 2 products under one NDC; Tirosint® (levothyroxine) capsules; Colcyrs® (colchicines) tablets;
Quantity edits added to: prenatal vitamins; topiramate 25 mg and 50 mg tablets; cough products; change on qty edit for Migranal® 4 mg/ml nasal spray;
Changes to coverage in the optional coverage category of cough products.
5/3/2010 NCPDP Field Requirement
2/25/2010 Arkansas Medicaid DUR Board edits approved at the Jan. 20, 2010 meeting:
Singulair® cumulative quantity edit added; Singulair® clinical edits clarified; Cold Products containing either pseudoephedrine or chlorpheniramine plus a drying agent; Ciclopirox 8% Kit; Bensal® HP ointment; Zinotic® and Zinotic® ES ear drops; Terbinex Kit.
12/10/2009 Clinical edits and quantity edits on Invega® Sustenna™; clinical edits on anti-inflammatory ophthalmic drops; clinical edits on Nucort® 2% Lotion and Nuzone® 2% Gel; clinical edits on Metozolv® ODT tablets; quantity edit on Zovirax® 15 gm ointment; clinical edits on Ulesfia® 5% Lotion; clinical edits on hemorrhoid preparations; clinical edits on first generation antihistaminedecongestant liquid and oral solid dosage forms
8/12/2009 Clonidine & guanfacine qty edits amended; Synagis® PA criteria updates; clinical edits amended for opioids; Hepatitis C medication therapy meds; Ranexa® clinical edits amended; new clinical edits and/or claim edits added for the following medications: overactive bladder medications; Lamictal® ODT tablets; Riomet® 500 mg/5 ml oral solution; Gastrocom® 100 mg/5 ml concentrate; Valcyte® tablet; Synarel® Nasal Spray; Xenazine® tablets; Floxin® Otic Singles, Ciprofloxacin ER tablets & Proquin® XR tablets; Moxatag® ER tablets; Mepron® 750/5 ml suspension; Topical Antifungal Agents, including cream, solution, lotion and shampoo; antibiotic ophthalmic drops; Altabax® ointment; Cetraxal® Otic Singles; Zonalon® 5% & Prudoxin® 5% (doxepin 5%) cream.
4/27/2009 Effective July 7, 2009: Antipsychotics oral agents, clonidine, & guanfacine therapeutic duplication edits, age edits, and quantity and dose edits in recipients < 18 years of age; manual review on all antipsychotic agents for recipients < 5 years of age; clinical edits on oral dissolvable tablets or liquids for atypical antipsychotics for all ages; quantity and dose edits for the following drugs: chloral hydrate liquid and capsules, Transderm Scōp® patch, Bactroban® nasal oint, Tyzine® nasal spray and drops; manual review for Milipred®; Effective July 21, 2009: ADD/ADHD medications listed for preferred and non-preferred status, addition of preferred medications, Strattera® clinical edits and manual review for recipients < 5 years of age; Effective August 11, 2009: Asthma medications listed for preferred and non-preferred status, edits for select non-preferred agents used in asthma; Singulair® clinical edits for asthma monotherapy or allergic rhinitis; Effective immediately: to prevent billing errors, dose and quantity edits on Moxatag ER 775 mg & Proquin XR 500 mg;
3/11/2009 SGAD criteria amended; opioid criteria amended to include tramadol IR, tramadol/APAP and tramadol ER, and new denial criteria for patients receiving treatment for opioid dependence; modified appropriate package-size edit table to include additional non-solid dosage form products; new clinical edits and/or claim edits added for Veripred® oral solution, Suboxone®, Subutex®, TZD combination products, and Letairis®.
11/10/2008 Revised clinical therapeutic duplication edits for all short-acting and long-acting opioids; clinical criteria for Axid® (nizatidine) oral solution, Lupron injection claim edits.
8/1/2008 Dose edits, quantity edits, and clinical therapeutic duplication edits for all short-acting and long-acting opioids; clinical edits and/or claim edits (quantity/dose, age, or gender) on Relistor® (methylnaltrexone bromide SQ injection, Pepcid® (famotidine) oral su0spension, Baraclude® (entecavir) tablets, and non-pediculicide medicated shampoos (Capex® (fluocinolone acetonide), Clobex® shampoo (clobetasol proprionate), Loprox® shampoo (ciclopirox), selenium sulfide shampoo, ketoconazole, salicylic acid shampoo), NovoSeven® RT (Coagulation Factor VIIa Recombinant) Intravenous bolus injection.
5/20/2008 Clinical edits, and claim edits (quantity/dose, age, or gender) for Pamine®, Pamine Forte®, Pamine FQ® kit, Veregen® ointment 15%, minocycline & doxycycline solid dosage forms, Auralgan® ear drops, oral liquids packaged and dosed as drops, tramadol immediate release and Ultram® ER; FYI section for Plan B®, and Incarcerated persons; Corrections or changes to previous edits for Vusion® ointment, NTG patches, and LABA/ICS combination products.
2/12/2008 Clinical edits, and claim edits (quantity/dose, age, or gender) for ESAs, topical corticosteroids, Vusion ointment, Soriatane capsules, DDAVP nasal preparations, Panafil SE aerosol, Entocort EC capsules, Zovirax 5% cream, Denavir 1% cream. Clarification of Invega, Noxafil, & AEVCS edits implemented Jan. 2008
12/13/2007 Notice of Third Party Billing
11/28/2007 Clinical edits, and claim edits (quantity/dose, age, or gender) for Anabolic steroids oxandrolone, nandrolone decanoate inj., oxymethalone; Cytotec tablets; Invega tablets; Condylox gel and solution; Noxafil suspension; Pulmozyme inhalation solution; TOBI inhalation solution; Taclonex ointment; Xolegel 2% and Xolegel Duo Convenience Pack; Ponstel capsules; Targretin gel
8/8/2007 Clinical edits, Age edits, and or Quantity/Dose edits: CATAPRES TTS patches, KETEK tablets, JANUVIA tablets, TEKTURNA tablets, SEROQUEL XR tablets, CHANTIX tablets, AMITIZA tablets, and ACETAMINOPHEN and ACETAMINOPHEN COMBINATION drugs
5/23/2007 Clinical edits and quantity/dose edits: Marinol® capsules; Cesamet® capsules; Qualaquin® capsules; Aldara® cream; Forteo® injection; Amitiza® capsule. Quantity/dose edits: Actos®; Avandia®; Cozaar®, Hyzaar®; estradiol; estropipate; Nexium®; Prevacid®; simvastatin. Emergency Override process. Tramadol listed as a controlled drug. Flovent® HFA and QVAR® HFA for respiratory insufficiency patients.
2/6/2007 Qty edits on contraceptive agents; age edit and qty edit on Protopic ointment; clinical edits and revised dose edits for ADD/ADHD drugs; new edit alert for incorrect decimal package size billed
12/4/2006 Clinical edits on Celebrex, Lidoderm Patch, Exubera, Growth Hormones;
Quantity limits on Oxytrol Patch, Zelnorm, Strattera, Neulasta, Exubera
9/18/2006 Clinical edits on Ranexa, Serostim, Megace and Megace ES;
Quantity limits on Ranexa, Megace, Megace ES, Miacalcin, Tamiflu suspension, Tamiflu capsules, Glucagon Emergency Kits, and Singulair
9/15/2006 Therapeutic Duplication, Dose Optimization, and Quantity limits on C-II Stimulants
7/10/2006 Quantity limit edits on Elidel Cream, Inhalers, Nasal Sprays, Ophthalmics, and Otics
5/15/2006 Clinical Edits on Long Acting Beta Agonists, Tequin, Byetta, and Symlin. Therapeutic Duplication on Sedative Hypnotics.
Quantity limit edits on Rebif, Byetta, Combunox, and Enbrel
3/16/2006 Quantity limit edits on Arixtra, Fragmin, Lovenox, Innohep, Diflucan 150 mg tablet, Lyrica
2/16/2006 Quantity limit edit and PA criteria edit on Lindane shampoo, Lindane Lotion, Ovide Lotion;
Quantity limit edit on Risperdal Consta
1/5/2006 Dose edits
10/20/2005 Transition of Products for Smoking Cessation from Voice Response System to Electronic Point of Sale (POS) System Modification
12/1/2004 Electronic Point of Sale (POS) System Modification Enhancement for Prescription Drugs
Date Description
02/14/19 Capped Upper Limits effective March 01, 2019
09/18/18 Capped Upper Limits effective October 15, 2018
10/09/17 Capped Upper Limits effective November 01, 2017
04/11/17 Capped Upper Limits effective May 01, 2017
02/24/17 Capped Upper Limits effective March 15, 2017
12/16/16 Capped Upper Limits effective January 01, 2017
11/10/16 Capped Upper Limits effective November 30, 2016
08/18/16 Capped Upper Limits effective September 01, 2016
07/22/16 Capped Upper Limits effective August 15, 2016
02/01/16 Capped Upper Limits effective February 01, 2016
10/01/14 Capped Upper Limits effective October 01, 2014
Date Description
01/28/16 Generic Upper Limits changing effective February 15, 2016
01/15/16 Generic Upper Limits changing effective January 15, 2016
07/15/14 GUL Effective date
06/01/14 GUL Effective date
03/15/14 GUL Effective date
10/01/13 GUL Effective date
09/01/13 GUL Effective date
07/15/13 GUL Effective date
06/30/13 GUL Effective date