016.29.22 Ark. Code R. § 011 - Pharmacy (1-22) Provider Manual change for combining the DUR Board and DRC

240.000 PRIOR AUTHORIZATION

Prescription drugs may be reimbursed under the Arkansas Medicaid Program pursuant to an order from an authorized prescriber.

The prescriber must initiate the prior authorization (PA) for prescription drugs that require PA. The PA request must be completed and submitted by the prescriber. All PA documentation must remain in the patient's chart and will be subject to audit by the Division of Medical Services or its authorized representatives.

In addition, clinical edits will be established through a system modification enhancement, as well as limits placed on drugs based on age, gender, quantity, and dosage, as approved by our Drug Utilization Review Board. Lists of all drugs, subject to clinical editing and the criteria for reimbursement, are maintained by DHS or its contracted Pharmacy Vendor. View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.

Arkansas Medicaid Pharmacy Program will maintain a Preferred Drug List based on comparative evidence-based data from Clinical Evidence Reports (CER). Arkansas Medicaid Pharmacy Program will use the CER to identify drug class or drug classes of medications that have similar indications, efficacy, and safety. Arkansas Medicaid will negotiate state supplemental rebates with manufacturers for the identified medication(s), pursuant to a CMS approved State Supplemental Rebate Agreement. A Drug Cost Committee (DCC) will review both State Supplemental and Federal rebates to determine the final net cost to the State. The Drug Utilization Review (DUR) Board will review the CER to determine safety and efficacy of the identified medication(s). The DCC and DUR Board will provide recommendations to the State for preferred and non-preferred status for the identified medication(s). Arkansas Medicaid will use these recommendations to establish and maintain a Preferred Drug List.

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 DHS Contracted Pharmacy Vendor 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 one (1) time per year per drug class for non-LTC beneficiaries and one (1) time per sixty (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.

Prior Authorization information is maintained by DHS or its contracted Pharmacy Vendor. View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.

The following information is available:

A. Prescription Drug Clinical Edits
B. Prescription Drug Claim Edits
C. Prescription Drug PA Forms
D. VRS System Brochure, and
E. Evidence-Based Prescription Drug Program.

Notes

016.29.22 Ark. Code R. § 011
Adopted by Arkansas Register Volume 48, Number 1, Effective 12/26/2022

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