Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.07-044 - Pharmacy Update #100 & State Plan Amendment #2007-009

Current through Register Vol. 49, No. 6, June, 2024
Section 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.