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.
