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This document is an informational listing of the medications requiring a Prior Authorization through the Arkansas Medicaid Pharmacy Program, and a description of the associated criteria. Inclusion in this document does not guarantee market availability and products must meet the Centers for Medicare and Medicaid Services (CMS) definition of a covered outpatient drug and pay CMS rebate to be covered by Arkansas Medicaid. Select covered over the counter medications are covered pursuant to a valid prescription, but are not covered for Long Term Care eligible beneficiaries.

Arkansas Medicaid Prescription Drug Program Prior Authorization Criteria Appendix F ­ Antineoplastics to Infer Malignant Cancer Appendix G ­ Chronic Obstruction Pulmonary Disease Diagnoses Appendix H ­ Approved Diagnoses for nonpreferred Antiepileptic Agents in Neuropathic Pain Agent Class Appendix I ­ Approved Endoscopy Code

Prescribers may request an override for nonpreferred drugs by calling the UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk at 1-866-250-2518 (toll-free) or 501-526-4200 (local).

Ondansetron HCl 4mg, 8mg tablet (Zofran) Ondansetron 4mg, 8mg oral-disintegrating tablet (Zofran ODT) Ondansetron 4mg/2ml preservative-free vial (Zofran) Ondansetron 40mg/20ml vial (Zofran)

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