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Magellan Medicaid Administration Pharmacy Help Desk
(800) 424-7895, Option 2 for Prescribers

Pharmacy

The following documents are available for this provider type. See also Instructions for Handling Files and All Providers.

Current Dental Terminology, © 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Magellan Medicaid Administration
Memorandums
Provider Manual
Notices of Rule Making
Official Notices
RA Messages

Magellan Medicaid Administration

Additional Pharmacy information can be found at the Magellan Medicaid Administration website (HTML, new window).

Memorandums

Date Topic
11/27/19 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board October 16, 2019 meeting and PDL changes approved by the PDL Review Committee meeting November 13, 2019
10/30/19 Special Memorandum from DMS Pharmacy Program - Updates and Information
8/28/19 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board July 17, 2019 meeting and PDL changes approved by the PDL Review Committee meeting August 14, 2019
5/17/19 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board April 17, 2019 meeting and PDL changes approved by the PDL Review Committee meeting May 8, 2019
2/14/19 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board January 16, 2019 meeting and PDL changes approved by the PDL Review Committee meeting February 13, 2019
8/30/18 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board July 18, 2018 meeting and PDL changes approved by the PDL Review Committee meeting August 8, 2018
5/31/18 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board April 18, 2018 meeting and PDL changes approved by the PDL Review Committee meeting May 9, 2018
3/1/18 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board January 17, 2018 meeting and PDL changes approved by the PDL Review Committee meeting February 17, 2018
1/31/18 Clarification of New Opioid Criteria Rules
11/22/17 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board October 18, 2017 meeting and PDL changes approved by the PDL Review Committee meeting November 8, 2017
9/1/17 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board July 19, 2017 meeting and PDL changes approved by the PDL Review Committee meeting August 9, 2017
5/30/17 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board April 19, 2017 meeting and PDL changes approved by the PDL Review Committee meeting May 10, 2017
2/20/17 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board January 18, 2017 meeting and PDL changes approved by the PDL Review Committee February 1, 2017
12/14/16 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board October 19, 2016 meeting and PDL changes approved by the PDL Committee November 9, 2016
8/29/16 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board July 20, 2016 meeting
6/8/16 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board April 20, 2016 meeting
3/16/16 Arkansas Medicaid PA edits approved at the Arkansas Medicaid DUR Board January 20, 2016 meeting
1/8/16 Arkansas Medicaid DUR Board edits approved at the October 21, 2015 meeting
8/14/15 Arkansas Medicaid DUR Board edits approved at the April 15, 2015 meeting
6/15/15 Arkansas Medicaid DUR Board edits approved at the April 15, 2015 meeting
3/12/15 Arkansas 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
2/10/15 New Medicaid Pharmacy Vendor
1/26/15 New Medicaid Pharmacy Vendor
12/19/14 New Medicaid Pharmacy Vendor
11/26/14 Arkansas 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
9/15/14 New Medicaid Pharmacy Vendor
8/18/14 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
5/21/14 AR Medicaid DUR Board edits approved at the April 16, 2014 meeting:
Changes To Existing Prior Authorization (PA) Criteria Or Edits: C-II 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
2/12/14 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 multi-dose 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
11/8/13 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)
10/21/13 NCPDP Field Requirement
8/5/13 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 dose-optimization 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
6/6/13 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
2/8/13 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
11/19/12 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.
8/30/12 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.
8/1/12 System Confirmation of (6) Month Prescription Allowance
6/5/12 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.
3/15/12 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.
11/23/11 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.
8/31/11 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.
5/17/11 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.
3/11/11 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.
12/8/10 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
8/26/10 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;
6/11/10 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.
5/3/10 NCPDP Field Requirement
2/25/10 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.
12/10/09 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 antihistamine-decongestant liquid and oral solid dosage forms
8/12/09 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.
4/27/09 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;
3/11/09 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®.
11/10/08 Revised clinical therapeutic duplication edits for all short-acting and long-acting opioids; clinical criteria for Axid® (nizatidine) oral solution, Lupron injection claim edits.
8/1/08 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.
5/20/08 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.
2/12/08 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
12/13/07 Notice of Third Party Billing
11/28/07 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
8/8/07 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
5/23/07 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.
2/6/07 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
12/4/06 Clinical edits on Celebrex, Lidoderm Patch, Exubera, Growth Hormones; Quantity limits on Oxytrol Patch, Zelnorm, Strattera, Neulasta, Exubera
9/18/06 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
9/15/06 Therapeutic Duplication, Dose Optimization, and Quantity limits on C-II Stimulants
7/10/06 Quantity limit edits on Elidel Cream, Inhalers, Nasal Sprays, Ophthalmics, and Otics
5/15/06 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
3/16/06 Quantity limit edits on Arixtra, Fragmin, Lovenox, Innohep, Diflucan 150 mg tablet, Lyrica
2/16/06 Quantity limit edit and PA criteria edit on Lindane shampoo, Lindane Lotion, Ovide Lotion; Quantity limit edit on Risperdal Consta
1/5/06 Dose edits
10/20/05 Transition of Products for Smoking Cessation from Voice Response System to Electronic Point of Sale (POS) System Modification
12/1/04 Electronic Point of Sale (POS) System Modification Enhancement for Prescription Drugs

Provider Manual

Section I – General Medicaid Policy

  • Section I
  • Section I Update Log
  • All Provider Manuals Publications / Notifications

Section II – Program Policy

  • Section II
  • Section II Update Log
  • Program Publications / Notifications

Section III – Billing Information

Section IV – Glossary

Section V – Forms and Contacts

Notices of Rule Making

Date Number Subject
None

Official Notices

Date Number Subject
10/1/19 ON-004-19 2020 International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS)
3/26/19 ON-001-19 2019 Healthcare Common Procedure Coding System Level II (HCPCS) Code Conversion and Code on Dental Procedures and Nomenclature (CDT) Conversion
3/26/19 ON-002-19 2019 Current Procedural Terminology (CPT®) Code Conversion

RA Messages

Date Subject
3/7/19-3/28/19 Provider-led Arkansas Shared Savings Entity (PASSE) UPDATE
2/14/19-2/28/19 New CAP Rates
1/31/19-3/28/19 Provider-led Arkansas Shared Savings Entity (PASSE) Will Go Live on March 1, 2019
9/27/18-10/11/18 New CAP Rates