Pharmacy Forms & Resources

Authorization Forms

• Arkansas Medicaid Prescription Drug Program Statement of Medical Necessity Prior Authorization Request
• Arkansas Medicaid Medication Assist Treatment (MAT) Pharmacotherapy VIVITROL IM
• Arkansas Medicaid Prescription Drug Program Synagis Prior Authorization Request Form
• Arkansas Medicaid Prescription Drug Program Hepatitis C Virus (HCV) Medication Therapy PA Request Form
• Statement of Medical Necessity Information Form for Ingrezza or Austedo
• Arkansas Medicaid Prescription Drug Program Selzentry Statement of Medical Necessity
• Arkansas Medicaid Medication Assisted Treatment (MAT) Pharmocotherapy Injectable Buprenorphine-Containing Agents
• Arkansas Medicaid Prior Authorization Request Form H.P. Acthar gel (cortiocotropin injection)
• Statement of Medical Necessity Information Form for Invega Trinza
• Arkansas Medicaid Prescription Drug Program Statement of Medical Necessity for Xolair
• Statement of Medical Necessity for Adult use of a C-II Stimulant

Mail Order Forms

• Caremark Mail Service Order Form

Diabetes Supply Formulary

• Diabetes Supply Formulary

Payer Sheets

• Payer sheet for Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Amount Paid (OPAP)
• Payer sheet for Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Patient Responsibility (OPPR)

Claim Forms

• Prescription Reimbursement Claim Form (Standard)
• Prescription Reimbursement Claim Form (Spanish)

Medication Informed Consent

• Medication Informed Consent Document <18 years old
• Medication Informed Consent Document

Empower Prospective DUR

• Empower Prospective DUR

Compound prescriptions

Compounded prescription claims may be submitted to the Program when multiple ingredients are used in the preparation of the medication provided to the Arkansas Medicaid beneficiary.  Up to twenty-five (25) National Drug Codes (NDCs) may be submitted for compounded prescription claims.  The provider must indicate the metric decimal quantity of each submitted NDC.  The metric decimal quantity field at the header level should reflect the total quantity of the final compounded prescription.  A prescription is only considered a compounded prescription if two or more NDCs are submitted as ingredients on the claim.  If one or more of the ingredients is not payable by the Program, the cost of those non-covered products will not be included in the payment for the claim.  If the pharmacist opts to provide a compounded prescription in spite of the non-coverage of one or more ingredients, the beneficiary is not responsible for the cost of any non-covered ingredients used to prepare the prescription, but only for the applicable co-payment. The provider may submit a Prescription Clarification Code of 08 (in field 420-DK) to accept payment for only the covered ingredients of the compound.  If the Prescription Clarification Code of 08 is not submitted, the program will reject the claim with an error message informing the provider of the non-covered status of one or more ingredients.  The compounded prescription claim, with two to twenty-five ingredients, will count as one claim against the Medicaid beneficiary’s prescription drug benefit limit. Due to provisions set forth in the Omnibus Budget Reconciliation Act (OBRA 90), only the NDC that is dispensed and the quantity of the NDC that is dispensed can be submitted to Medicaid.  If a pharmacy provider is unable to bill according to these guidelines due to software limitations, the vendor should be notified of these requirements immediately.  Any pharmacy that continues to bill compounded prescription claims improperly will be subject to recoupment of the total paid amount of those claims.