Medwatch Patient Information Request Form printable pdf download

Medwatch Patient Information Request Form

OFFICIAL NOTICE

DMS-2002-O-7

DMS-2002-E-5

DMS-2002-KK-11

DMS-2002-Q-8

DMS-2002-R-15

TO:

Health Care Provider – Certified Nurse-Midwives,

Dental, Nurse Practitioners, Pharmacy and Physicians

DATE:

SUBJECT:

Prescription Drug Program Requirement for

Documentation of Medical Necessity for Brand Name

Drugs with a Generic Upper Limit

Effective for claims with dates of service on or after October 15, 2002, the

Arkansas Department of Human Services is amending the conditions required

to override the Generic Upper Limit cost on brand name drugs when a generic

equivalent is available. The requirements are attached which outline

introduction, definition and procedure.

If you need this material in an alternative format, such as large print, please

contact our Americans with Disabilities Act Coordinator at (501) 682-8307

(voice) or at (501) 682-6789 and 1-877-708-8191 (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.

Ray Hanley, Director

Arkansas Medicaid provider manuals (including update transmittals), official

notices and remittance advice (RA) messages are available for downloading

from the Arkansas Medicaid website:

Medwatch Patient Information Request Form