016.06.07 Ark. Code R. 044
Current through Register Vol. 49, No. 10, October, 2024
Rule 016.06.07-044 - Pharmacy Update #100 & State Plan Amendment #2007-009Section II Pharmacy 241.000 Coverage of Tobacco Cessation Products Effective for claims with dates of service on or after October 1, 2004, coverage of tobacco cessation products is available with prior authorization (PA) to eligible Medicaid beneficiaries. PA criteria can be found at www.medicaid.state.ar.usor
https:///www.medicaid.state.ar.us/Download/provider/pharm/Criteria.doc# cApproval Crit eria.
Coverage and Limitations
A. Reimbursement for generic Zyban if appropriate, and nicotine replacement therapy (NRT), either nicotine gum or nicotine patches is available for up to 187 days of treatment within a calendar year for eligible Medicaid beneficiaries. Varenicline is also available for reimbursement for up to 187 days of treatment within a calendar year. Pregnant females are allowed up to four ninety-three day courses of treatment per calendar year. One course of treatment is three consecutive months.B. Additional prescription benefits are allowed per month for tobacco cessation products during the approved PA period and will not count against the monthly prescription benefit limit. One benefit is allowed for generic Zyban if the physician believes that generic Zyban therapy is appropriate and one benefit for nicotine replacement therapy, either nicotine gum or patches.Concurrent use of Varenicline with generic Zyban or NRT is not indicated and will not be allowed. Tobacco cessation products are not subject to co-pay.C. Over the counter (OTC) as well as any legend products are eligible for reimbursement. OTC products are not covered for long term care residents.AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
ATTACHMENT 3.1-A
12. Prescribed drags, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist a. Prescribed Drags (1) Each recipient age 21 or older may have up to six (6) prescriptions each month under the program. The first three prescriptions do not require prior authorization. The three additional prescriptions must be prior authorized. Family Planning, tobacco cessation and EPSDT prescriptions do not count against the prescription limit.(2) Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.(3) The Medicaid agency provides coverage, to the same extent that it provides coverage for all Medicaid recipients, for the following excluded or otherwise restricted drags or classes of drags, or their medical uses - with the exception of those covered by Part D plans as supplemental benefits through enhanced alternative coverage as provided in 42 C.F.R. § 423.104(f) (1) (ii) (A) - to full benefit dual eligible beneficiaries under the Medicare Prescription Drag Benefit - Part D. The following excluded drags, set forth on the Arkansas Medicaid Website (www.medicaid.state.ar.us/InternetSolution/Provider/pharm/scripinfo.aspx#1927d), are covered:
a. select agents when used for weight gain: Androgenic Agents b. select agents when used for the symptomatic relief of cough and colds:
Antitussives; Antitussive-Decongestants; Antitussive-Expectorants c. select prescription vitamins and mineral products, except prenatal vitamins and fluoride:
B 12; Folic Acid, Vitamin K
d. select nonprescription drugs: Antiarthritics; Antibacterials and Antiseptics; Antitussives; Antitussives-Expectorants; Analgesics; Antipyretics; Antacids; Antihistamines; Antihistamine-Decongestants; Antiemetic/Vertigo Agents; Antimalarial; ; Electrolytes and Miscellaneous Nutrients; Emollients; Fat Soluble Vitamins; Gastrointestinal Agents; General Inhalation Agents; Hematinics; Laxatives; Opthalmic Agents; Respiratory Aids; Sympathomimetics; Topical Antibiotics; Topical Antifungals; Topical Antiparasitics; Vaginal Antifungals; Nicotine Gum; Nicotine Patches; Generic Zyban, Varenicline
e. all barbiturates f all benzodiazepines(4) The State will reimburse only for the drugs of pharmaceutical manufacturers who have entered into and have in effect a rebate agreement in compliance with Section 1927 of the Social Security Act, unless the exceptions in Section 1902(a)(54), 1927(a)(3) or 1927(d) apply. The State permits coverage of participating manufacturers' drags, even though it may be using a formulary or other restrictions. Utilization controls will include prior authorization and may include drag utilization reviews. Any prior authorization program instituted after July 1, 1991 will provide for a 24-hour turnaround from receipt of the request for prior authorization. The prior authorization program also provides for at least a 72 hour supply of drags in emergency situations.12. Prescribed drags, dentures and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist b. Prescribed Drags(1) Each recipient age 21 or older may have up to six (6) prescriptions each month under the program. The first three prescriptions do not require prior authorization. The three additional prescriptions must be prior authorized. Family Planning, tobacco cessation and EPSDT prescriptions do not count against the prescription limit.(2) Effective January 1, 2006, the Medicaid agency will not cover any Part D drag for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.(3) The Medicaid agency provides coverage, to the same extent that it provides coverage for all Medicaid recipients, for the following excluded or otherwise restricted drags or classes of drags, or their medical uses - with the exception of those covered by Part D plans as supplemental benefits through enhanced alternative coverage as provided in 42 C.F.R. § 423.104(f) (1) (ii) (A) - to full benefit dual eligible beneficiaries under the Medicare Prescription Drag Benefit - Part D. The following excluded drags, set forth on the Arkansas Medicaid Website (www.medicaid.state.ar.us/InternetSolution/Provider/pharm/scripinfo.aspx#1927d), are covered:
a. select agents when used for weight gain: Androgenic Agents b. select agents when used for the symptomatic relief of cough and colds:
Antitussives; Antitussive-Decongestants; Antitussive-Expectorants c. select prescription vitamins and mineral products, except prenatal vitamins and fluoride:
B 12; Folic Acid; Vitamin K
d. select nonprescription drags: Antiarthritics; Antibacterials and Antiseptics; Antitussives; Antitussives-Expectorants; Analgesics; Antipyretics; Antacids; Antihistamines; Antihistamine-Decongestants; Antiemetic/Vertigo Agents; Antimalarial; Electrolytes and Miscellaneous Nutrients; Emollients; Fat Soluble Vitamins; Gastrointestinal Agents; General Inhalation Agents; Hematinics; Laxatives; Opthalmic Agents; Respiratory Aids; Sympathomimetics; Topical Antibiotics; Topical Antifungals; Topical Antiparasitics; Vaginal Antifungals;
Nicotine Gum; Nicotine Patches; Generic Zyban, Varenicline
e. all barbiturates f all benzodiazepines(4) The State will reimburse only for the drags of pharmaceutical manufacturers who have entered into and have in effect a rebate agreement in compliance with Section 1927 of the Social Security Act, unless the exceptions in Section 1902(a)(54), 1927(a)(3) or 1927(d) apply. The State permits coverage of participating manufacturers' drags, even though it may be using a formulary or other restrictions. Utilization controls will include prior authorization and may include drag utilization reviews. Any prior authorization program instituted after July 1, 1991 will provide for a 24-hour turnaround from receipt of the request for prior authorization. The prior authorization program also provides for at least a 72 hour supply of drags in emergency situations.016.06.07 Ark. Code R. 044