016.06.04 Ark. Code R. § 006 - Official Notice DMS-2004-L-1, DMS-2004-KK-1, DMS-2004-R-1

Influenza Virus Vaccine, Live, for Intranasal Use, CPT Procedure Code 90660, and Prior Approval of New Pharmacy and Therapeutic Agents

I. Influenza Virus Vaccine, Live, for Intranasal Use

A. Influenza virus vaccine, live, for intranasal use (CPT procedure code 90660) is covered by the Arkansas Medicaid Program for ages 5 and older, for dates of service before May 1, 2004.

B. Effective for dates of service on and after May 1, 2004, this vaccine will not be covered.

II. Prior Approval of New Pharmacy and Therapeutic Agents

A. Effective for dates of service on and after May 1, 2004, providers must obtain prior approval, in accordance with the following procedures, for new pharmacy and therapeutic agents.

1. Before you may begin treatment, the Medical Director for the Division of Medical Services (DMS) must approve any drug not listed as covered in your provider manual or in official DMS correspondence.

2. This requirement also applies to any drug with special instructions regarding coverage in the provider manual or in official DMS correspondence.

B. The Medical Director's prior approval is necessary to ensure payment of the provider's charges.

1. The provider must submit a history and physical examination with the treatment protocol before beginning the treatment.

2. The provider will be notified by mail of the DMS Medical Director's decision.

C. Claims for prior-approved pharmacy and therapeutic agents must be submitted to EDS on paper.

1. Each claim must reflect, in the description of service field, the number in the treatment series of each administration for which you are billing Medicaid.

2. No prior authorization number is issued; therefore, a copy of the Medical Director's approval letter must be attached to each claim filed.

Send requests for prior approval of pharmacy and therapeutic agents to:

Division of Medical Services PO Box 1437, SlotS412 Little Rock, AR 72203-1437

Attention: Medical Director

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-6789 or 1-877-708 -8191. Both telephone numbers are voice and TDD.

If you have questions regarding this notice, please contact the EDS Provider Assistance Center at In-State WATS 1 - 800-457-4454, or locally and Out-of-State at (501) 376-2211.

Thank you for your participation in the Arkansas Medicaid Program.

Roy Jeffus, Director

Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Notes

016.06.04 Ark. Code R. § 006

4/6/2004