Medwatch Patient Information Request Form (Page 4 of 5) in pdf

The Arkansas Medicaid Program may forward the completed MedWatch forms to the

FDA. Requests will be reviewed by the EDS Pharmacy Help Desk and approved or

denied based on preceding definitions. If it is necessary for the EDS Pharmacy Help Desk

to have further correspondence with the prescriber, the status of the prior authorization

will be pending until contact is made with the prescriber and a decision is made as to the

status of the request. EDS will notify the prescribing and dispensing providers, by the

close of the following business day, excluding weekends and holidays, of approval,

denial, or additional documentation by way of the MedWatch Patient Information

Request Form (DMS-636). Prescribers may appeal denied prior authorization requests by

contacting the Pharmacists at the office of Division of Medical Services.

Recipients will be notified by mail of the denied Brand Medically Necessary prior

authorization. Approved MedWatch Prior Authorizations will be established for one year

at the pharmacy provider named on the MedWatch Patient Information Request form

(DMS-636). The EDS Pharmacy Help Desk will contact the pharmacy provider to

determine the NDC the pharmacy will be dispensing. The pharmacy provider will then

be informed of the prior authorization number and date range. The pharmacy will be

responsible for maintaining on file the original prescription with the “Brand Medically

Necessary” documentation. Renewal of a MedWatch Prior Authorization will require the

prescriber to resubmit a letter and a MedWatch Patient Information Request form (DMS-

636). A renewal does not require a resubmission of a MedWatch form.

II. Prior Authorization Requirements

for drugs* not requiring MedWatch

Documentation:

FDA MedWatch form completion will not be required for recipients being treated with

the following drug products:

Carbamazepine

Primidone

Valproic Acid

Warfarin

*Drugs may be added or deleted to the list of drugs not requiring a MedWatch Prior

Authorization.

As required by the Code of Federal Regulations, 42 CFR 447.331, all prescriptions for

drugs with GULs are required to have in the prescriber’s own handwriting, “Brand

Medically Necessary” in order for the pharmacy to receive payment exceeding the

Generic Upper Limit established by the Program. The prescription with the necessary

documentation is to be provided to the pharmacy provider to alert the provider of the

need for a prior authorization for a non MedWatch drug. It is the responsibility of the

Pharmacist to obtain this documentation on all “Brand Medically Necessary”

prescriptions in order to submit DAW 1 code to override the GUL. The pharmacy will

establish a Prior Authorization through the Voice Response System and transmit a DAW

code of 1 to override the Generic Upper Limit if the prescription has the required

notation. The pharmacy will be responsible for maintaining on file the original

prescription with the “Brand Medically Necessary” notation.

Medwatch Patient Information Request Form Page 4