Medicaid Managed Care Services (MMCS) PCP Packet

Transcription

1 Medicaid Managed Care Services (MMCS) PCP Packet Arkansas Health Care Payment Improvement Initiative (AHCPII) Patient Centered Medical Home (PCMH) n 24/7 Best practices n Care coordination Community Care of North Carolina FOR MORE INFORMATION, CONTACT: Tonyia Haynes, Senior Program Coordinator [email protected] 4TH QUARTER, SFY APRIL 1 JUNE 30, 2015 Click below to view any of the materials in this quarter s packets. Note: Some links will open a webpage. n Guide to reading your PCMH quarterly report Sample PCMH quarterly report n Guide to selecting high priority beneficiaries n PCMH FAQs n PCMH manual docs/pcmh.aspx n PCMH QA Care plans 18-Month activities n Practice transformation Qualis Health Arkansas Foundation for Medical Care (AFMC) n Congestive Heart Failure n Coronary Artery Bypass Graft n Oppositional Defiant Disorder n Tonsillectomy n Total Joint Replacement n Upper Respiratory Infection Links n Arkansas Medicaid Information Interchange (AMII) User guide n Dental update As a result of ACT 90 of 2011, Arkansas physicians, nurses, and other licensed health care professionals as well as dentists, dental hygienists, and dental assistants can now apply fluoride varnish. As of Aug. 1, 2014, the Medicaid Provider Manual has been updated with this information. Visit Provider/docs/dental.aspx. Accept the copyright acknowledgement and click on Section II. You will find the added information in Section n EPSDT Billing sheet Fee schedule Foster care guidelines Screenings and sick visits Episodes of Care (Algorithms) n ADHD n Asthma n Cholecystectomy n Chronic Obstructive Pulmonary Disease n Colonoscopy CONTINUED, NEXT PAGE

2 Medicaid Managed Care Services (MMCS) PCP Packet FOR MORE INFORMATION, CONTACT: Tonyia Haynes, Senior Program Coordinator TH QUARTER, SFY APRIL 1 JUNE 30, 2015 Click below to view any of the materials in this quarter s packets. Note: Some links will open a webpage. n Health independence accounts (HIA) MyIndyCard.org MyIndyCard MyIndyCard Provider Provider FAQs Resource Guide MyIndyCard MyIndyCard Quickstart Pocket Guide User Guide n ICD-10 humanservices.arkansas.gov/dms/pages/icd-10.aspx n MMCS Update newsletter current edition mmcs.afmc.org/publications n MMCS PCP packet, electronic edition mmcs.afmc.org/healthcareprofessionals/ PCPUpdatePackets.aspx n MMCS provider representative contact information n PCP profile reports Log in at the link below to view your report. Provider/Provider.aspx n Preferred drug list (PDL) n Quality improvement project updates Antibiotic resistance tip sheet update: Visit the link below and click on Medicaid quality improvement tools afmc.org/tools BreastCare: Click on the following link for information on the BreastCare program and qualification guidelines. chronicdisease/arbreastcare/pages/default.aspx Breastfeeding CT imaging in the emergency department Opioids Pap smear/cervical cancer screening n Smoking cessation codes update n Third party liability form (DCO-662 TPL) update Call for assistance with adding or deleting insurance from a Medicaid beneficiary. n What s new for providers newprov.aspx THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. MP2-PCP.CD.4/15

3 Best Practices for Providing After-Hours Care Providing full continuity of care for patients requires physicians to provide some sort of system to handle patient crises after hours and on weekends. When communication is not available, patients either seek more expensive ER care or deteriorate, leading to more serious complications. Providing 24/7 physician communications is evolving as a professional standard of care and is an integral part of the medical home. Where improved after-hours communications have been implemented, patient satisfaction has increased and ER utilization has declined. BEST PRACTICES PCPs should have an after-hours system in place that ensures that patients can reach the PCP or another on-call medical professional with medical concerns or questions. This system should connect callers with a live voice either an answering service or afterhours personnel who should either forward patient calls directly to the on-call professional or instruct callers that the professional will return the call within 30 minutes. The answering service or after-hours personnel should ask the caller if the situation is an emergency. If so, the caller should be told to call 911 or go straight to the nearest ER. If staff or an answering service is not immediately available, the PCP/clinic may use an answering machine with a recorded message that directs callers to call 911 if they have an emergency, and to dial an alternate number (or system prompt) to reach an on-call professional. PCPs may provide access to an on-call professional through arranging with other PCPs to rotate call, or by contracting with a triage hotline service staffed by nurses or other clinical personnel. Records of after-hours calls should be made and entered into the patient s chart. AFTER-HOURS CARE PRACTICE ASSESSMENT To gauge your practice s performance in providing after-hours care, answer the following questions: n n n n n n Does your clinic provide access to a medical professional either an on-call provider or a telephone triage service staffed by clinical personnel to give callers voice-to-voice medical advice and guidance 24 hours, seven days a week? Does your clinic use an answering service or clinic staff to answer after-hours calls? If not, does your clinic use an answering machine that directs callers to dial an alternate number or system prompt to reach a live voice? If your clinic uses an answering machine, do you check it regularly to make sure it s working properly and the recorded message is current? Are non-emergency calls returned by a medical professional within 30 minutes? Are after-hours calls and their results documented and entered into patient records?

4 Example answering machine greeting ➊ You have reached [clinic name]. ➋ If this is an emergency, please hang up and dial 911 or go to the nearest hospital emergency room. ➌ If this is not an emergency and you would like to speak ➍ to an on-call doctor or nurse, please dial [answering service, on-call pager number, triage hotline number, etc.]. If the alternate number is to an on-call pager, add: A medical professional will return your call within 30 minutes. PROCESS FOR RECORDING AFTER-HOURS CALLS INTO A PATIENT S CHART FOLLOW UP: Contact patient and set appointment Check answering machine Retrieve messages Retrieve patient s chart Document call in chart FOLLOW UP: Contact patient and give referral FOLLOW UP: Contact patient and counsel For more information, contact your MMCS provider representative. THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT.

5 CARE COORDINATION SERVICES AVAILABLE PCMH-enrolled practices in Arkansas are eligible to receive care coordination services from Arkansas Community Cares, the state s only pre-qualified vendor for such services for Medicaid patients. Program Director Susan Beasley is available to meet with medical practices to discuss how our care managers can help your practice meet quality metrics necessary to achieve cost savings. Arkansas Community Cares offers care coordination services to help manage complex patients, support the medical home team and to ensure practices meet performance metrics necessary for shared savings. Care Coordination services are provided by highly-trained and skilled nurses who work directly with patients in your practice Care coordination includes, but is not limited to: o Assistance in identifying high-priority patients o Assistance in developing care plans for these patients o Scheduling twice-yearly preventive care visits o Arranging a primary care follow-up visit within 10 days of hospital discharge for highpriority patients o Educating patients on appropriate ER use and how best to access after-hours medical advice o Training patients in self-management skills. Arkansas Community Care is a subsidiary of Community Care of North Carolina (CCNC). CCNC s approach to healthcare was developed over two decades through a provider-led, community-based system of cost control and quality improvement in North Carolina s Medicaid program. An independent analysis of CCNC s work in North Carolina found that this quality-first approach avoided nearly a billion dollars in costs over a four-year period without slashing fees or creating burdensome administrative hurdles for physicians. Adding care managers to the primary care medical home team helps engage patients, betters manages handoffs between providers and treatment settings and saves physicians time by assisting with their most complex patients. Please contact Susan Beasley to schedule an appointment to learn more about how Arkansas Community Cares can assist you in achieving success! Susan Beasley [email protected]

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27 Patient-Centered Medical Home Section II SECTION II PATIENT CENTERED MEDICAL HOME (PCMH) CONTENTS DEFINITIONS ENROLLMENT AND CASELOAD MANAGEMENT Enrollment Eligibility Practice Enrollment Enrollment Schedule Caseload Management PRACTICE SUPPORT Practice Support Scope Practice Support Eligibility Care Coordination Payment Amount SHARED SAVINGS INCENTIVE PAYMENTS Shared Savings Incentive Payments Scope Shared Savings Incentive Payments Eligibility Pools of Attributed Beneficiaries Requirements for Joining and Leaving Pools Per Beneficiary Cost of Care Calculation Baseline and Benchmark Cost Calculations Shared Savings Incentive Payments Amounts METRICS AND ACCOUNTABILITY FOR PAYMENT INCENTIVES Activities Tracked for Practice Support Metrics Tracked for Practice Support Accountability for Practice Support Quality Metrics Tracked for Shared Savings Incentive Payments Provider Reports COMPREHENSIVE PRIMARY CARE (CPC) INITIATIVE PRACTICE PARTICIPATION IN THE PCMH PROGRAM CPC Initiative Practice Participation DEFINITIONS Attributed beneficiaries Attribution Benchmark cost Benchmark trend The Medicaid beneficiaries for whom primary care physicians and participating practices have accountability under the PCMH program. A primary care physician s attributed beneficiaries are determined by the ConnectCare Primary Care Case Management (PCCM) program. Attributed beneficiaries do not include dual eligible beneficiaries. The methodology by which Medicaid determines beneficiaries for whom a participating practice may receive practice support and shared savings incentive payments. The projected cost of care for a specific shared savings entity against which savings are measured. Benchmark costs are expressed as an average amount per beneficiary. The fixed percentage growth applied to PCMH practices historical baseline fixed costs of care to project Section II-1

28 Patient-Centered Medical Home Care coordination Care coordination payment Cost thresholds Default pool Historical baseline cost of care Medical neighborhood barriers Minimum savings rate Participating practice benchmark cost. The ongoing work of engaging beneficiaries and organizing their care needs across providers and care settings. Quarterly payments made to participating practices to support care coordination services. Payment amount is calculated per attributed beneficiary, per month. Cost thresholds are the per beneficiary cost of care values (high and medium) against which a shared savings entity s per beneficiary cost is measured. A pool of beneficiaries who are attributed to participating practices that do not meet the requirements in Section , part A or part B. A multi-year weighted average of a shared savings entity s per beneficiary cost of care. Obstacles to the delivery of coordinated care that exist in areas of the health system external to PCMH. A fixed percentage set by DMS. In order to receive shared savings incentive payments for performance improvement described in Section , part A, a shared savings entity must achieve a per beneficiary cost of care that is below its benchmark cost by at least the minimum savings rate. A physician practice that is enrolled in the PCMH program, which must be one of the following: A. An individual primary care physician (Provider Type 01 or 03); Section II B. A physician group of primary care providers who are affiliated, with a common group identification number (Provider Type 02, 04, or 81); C. A Rural Health Clinic (Provider Type 29) as defined in the Rural Health Clinic Provider Manual Section ; or D. An Area Health Education Center (Provider type 69). Patient-Centered Medical Home (PCMH) Per beneficiary cost of care Per beneficiary cost of care floor Per beneficiary savings A team-based care delivery model led by Primary Care Physicians (PCPs) who comprehensively manage beneficiaries health needs with an emphasis on health care value. The risk- and time-adjusted average of attributed beneficiaries total Medicaid fee-for-service claims (based on the published reimbursement methodology) during the performance period, net of exclusions. The lowest per beneficiary cost of care for which practices within a shared savings entity can receive shared savings incentive payments. The difference between a shared savings entity s benchmark cost and its per beneficiary cost of care in a given performance period. Section II-2

29 Patient-Centered Medical Home Performance period Pool The period of time over which performance is aggregated and assessed. A. The beneficiaries who are attributed to one or more participating practice(s) for the purpose of forming a shared savings entity; or Section II Practice support Practice transformation Primary Care Physician (PCP) Provider portal Recover Remediation time Risk adjustment B. The action of aggregating beneficiaries for the purposes of shared savings incentive payment calculations (i.e., the action of forming a shared savings entity). Support provided by Medicaid in the form of care coordination payments to a participating practice and practice transformation support provided by a DMS contracted vendor. The adoption, implementation and maintenance of approaches, activities, capabilities and tools that enable a participating practice to serve as a PCMH. See Section of this manual. The website that participating practices use for purposes of enrollment, reporting to the Division of Medical Services (DMS) and receiving information from DMS. To deduct an amount from a participating practice s future Medicaid receivables, including without limitation, PCMH payments, or fee-for-service reimbursements, to recoup such amount through legal process, or both. The period during which participating practices that fail to meet deadlines, targets or both on relevant activities and metrics tracked for practice support may continue to receive care coordination payments while improving performance. An adjustment to the cost of beneficiary care to account for patient risk. Same-day appointment request A beneficiary request to be seen by a clinician within 24 hours. Shared savings entity Shared savings incentive payment cap Shared savings incentive payments Shared savings percentage State Health Alliance for Records Exchange (SHARE) A participating practice or participating practices that, contingent on performance, may receive shared savings incentive payments. The maximum shared savings incentive payment that DMS will pay to practices in a shared savings entity, expressed as a percentage of that entity s benchmark cost for the performance period. Annual payments made to reward cost-efficient and quality care. The percentage of a shared savings entity s total savings that is paid to practice(s) in a shared savings entity as a shared savings incentive payment for performance improvement. The Arkansas Health Information Exchange. For more information, go to Section II-3

30 Patient-Centered Medical Home Section II ENROLLMENT AND CASELOAD MANAGEMENT Enrollment Eligibility To be eligible to enroll in the PCMH Program initially: A. The entity must be a participating practice as defined in Section B. The practice must include PCPs enrolled in the ConnectCare Primary Care Case Management (PCCM) Program. C. The practice may not participate in the PCCM shared savings pilot established under Act 1453 of D. The practice must have at least 300 attributed beneficiaries at the time of enrollment. DMS may modify the number of attributed beneficiaries required for enrollment based on provider experience and will publish at any such modification Practice Enrollment Enrollment in the PCMH program is voluntary and practices must re-enroll annually. To enroll, practices must access the provider portal and submit a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Practice Participation Agreement (DMS-844) available at Once enrolled, a participating practice remains in the PCMH program until: A. The practice withdraws; B. The practice or provider becomes ineligible, is suspended or terminated from the Medicaid program or the PCMH program; or C. DMS terminates the PCMH program. A physician may be affiliated with only one participating practice. A participating practice must update the Department of Human Services (DHS) on changes to the list of physicians who are part of the practice. This update must be submitted in writing within 30 days and ed to [email protected]. To withdraw from the PCMH program, the participating practice must a complete and accurate Arkansas Patient-Centered Medical Home Withdrawal Form (DMS-846) to [email protected]:///. View or print the Arkansas Patient-Centered Medical Home Withdrawal Form (DMS-846) or download the form from the provider portal Enrollment Schedule Initial enrollment periods are October 1, 2013 through December 15, 2013 and January 1, 2014 through May 15, Beginning with the 2015 calendar year, enrollment is open for approximately 3 months in Q3 and Q4 of the preceding year. DMS will return any enrollment documents received other than during an enrollment period Caseload Management A participating practice must manage its caseload of attributed beneficiaries, including removal of a beneficiary from its panel, according to the rules described in Section of this manual. Additionally, a participating practice must submit, in writing at the end of every calendar Section II-4

31 Patient-Centered Medical Home Section II quarter, an explanation of each beneficiary removal during such quarter. DMS retains the right to disallow these beneficiary removals. If a participating practice removes a beneficiary from its PCMH panel, then that beneficiary is also removed from its ConnectCare panel PRACTICE SUPPORT Practice Support Scope Practice support includes both care coordination payments made to a participating practice and practice transformation support provided by a DMS contracted vendor. Receipt and use of the care coordination payments is not conditioned on the practice engaging a care coordination vendor, as payment can be used to support participating practices investments (e.g., time and energy) in enacting changes to achieve PCMH goals. Care coordination payments are risk-adjusted to account for the varying levels of care coordination services needed for beneficiaries with different risk profiles. DMS will contract with a practice transformation vendor on behalf of participating practices that require additional support to catalyze practice transformation and retain and use such vendor. Practices must maintain documentation of the months they have contracted with a practice transformation vendor. Practice transformation vendors must report to DMS the level and type of service delivered to each practice. Payments to a practice transformation vendor on behalf of a participating practice may continue for up to 24 months. DMS may pay, recover or offset overpayment or underpayment of care coordination payments. DMS will also support practices through improved access to information through the reports described in Section Practice Support Eligibility In addition to the enrollment eligibility requirements listed in Section , in order for practices to receive practice support, DMS measures participating practice performance against activities tracked for practice support identified in Section and the metrics tracked for practice support identified in Participating practices must meet the requirements of these sections to receive practice support. Each participating practice that has pooled its attributed beneficiaries with other participating practices in a shared savings entity: A. Has its performance individually compared to activities tracked for practice support and metrics tracked for practice support. B. Will, if qualified, receive practice support even if other practices in a shared savings entity do not qualify for practice support Care Coordination Payment Amount The care coordination payment is risk adjusted (e.g., ranging from $1 to $30 per attributed beneficiary per month) based on factors including demographics (age, sex), diagnoses and utilization. After each quarter, DMS may pay, recover, or offset the care coordination payments to ensure that a practice did not receive a care coordination payment for any beneficiary who died or lost eligibility if the practice lost eligibility during the quarter. If a practice withdraws from the PCMH program, then the practice is only eligible for care coordination payments based on a complete quarter s participation in the PCMH program. Section II-5

32 Patient-Centered Medical Home Section II In order to begin receiving care coordination payments for the quarter starting January 1, 2014, a practice must submit a complete PCMH Practice Participation Agreement on or before December 15, In order to begin receiving care coordination payments for the quarter starting July 1, 2014, a practice must submit the PCMH Practice Participation Agreement on or before May 15, For all subsequent years, in order to participate in the PCMH program, a practice must submit the PCMH Practice Participation Agreement before the end of the enrollment period of the preceding year SHARED SAVINGS INCENTIVE PAYMENTS Shared Savings Incentive Payments Scope Shared savings incentive payments are payments made to a shared savings entity for delivery of economic, efficient and quality care that meets the requirements in Section Shared Savings Incentive Payments Eligibility To receive shared savings incentive payments, a shared savings entity must have a minimum of 5,000 attributed beneficiaries once the below exclusions have been applied. A shared savings entity may meet this requirement as a single practice or by pooling attributed beneficiaries across more than one practice as described in Section A. For purposes of calculating shared savings incentive payments only, the following beneficiaries shall not be counted toward the 5,000 attributed beneficiary requirement. 1. Beneficiaries that have been attributed to that entity s practice(s) for less than half of the performance period. 2. Beneficiaries that a practice prospectively designates for exclusion from per beneficiary cost of care (also known as physician-selected exclusions) on or before the 90 th day of the performance period. Once a beneficiary is designated for exclusion, a practice may not update selection for the duration of the performance period. The total number of physician-selected exclusions will be directly proportional to the practice s total number of attributed beneficiaries (e.g., up to one exclusion for every 1,000 attributed beneficiaries). 3. Beneficiaries for whom DMS has identified another payer that is legally liable for all or part of the cost of Medicaid care and services provided to the beneficiary. DMS may add, remove, or adjust these exclusions based on new research, empirical evidence or provider experience with select beneficiary populations. DMS will publish such addition, removal or modification on B. Shared savings incentive payments are conditioned upon a shared savings entity: 1. Enrolling during the enrollment period prior to the beginning of the performance period; 2. Meeting requirements for metrics tracked for shared savings incentive payments in section based on the aggregate performance for beneficiaries attributed to the shared savings entity for the majority of the performance period; and 3. Maintaining eligibility for practice support as described in Section Eligibility requirements for shared savings for Comprehensive Primary Care (CPC) practices are described in Section Pools of Attributed Beneficiaries Section II-6

33 Patient-Centered Medical Home Section II Participating practices will meet the minimum pool size of 5,000 attributed beneficiaries as described in by forming a shared savings entity in one of three ways: A. Meet minimum pool size independently; B. Pool attributed beneficiaries with other participating practices as described in In this method, practices voluntarily agree to have their performance measured together by aggregating performance (both per beneficiary cost of care and quality metrics tracked for shared savings incentive payments) across the practices; or C. Participate in a default pool if the practice does not meet the requirements for A or B of this section. Practices with beneficiaries in a default pool will have per beneficiary cost of care performance measured across the combined pool of all attributed beneficiaries in the default pool. There is no default pool in the first performance period beginning January 1, Requirements for Joining and Leaving Pools Practices may pool for purposes described in , part B, before the end of the enrollment period that precedes the start of the performance period. To pool, practices must submit to DMS a signed Arkansas Medicaid Patient-Centered Medical Home Practice Participation Agreement with a completed and accurate Arkansas Medicaid Patient-Centered Medical Home Pooling Request Form, available at executed by all practices participating in the pool. In the first performance period beginning January 1, 2014, a maximum of two practices may agree to voluntarily pool their attributed beneficiaries. Pooling is effective for a single performance period and must be renewed for each subsequent year. When a practice has pooled, its performance is measured in the associated shared savings entity throughout the duration of the performance period unless it withdraws from the PCMH program during the performance period. When a practice that has pooled withdraws from the PCMH program, the other practice or practices in the shared savings entity will have performance measured as if the withdrawn practice had never participated in the pool Per Beneficiary Cost of Care Calculation Each year the per beneficiary cost of care performance is aggregated and assessed across a shared savings entity. Per beneficiary cost of care is calculated as the risk- and time-adjusted average of such entity s attributed beneficiaries total fee-for-service claims (based on the published reimbursement methodology) during the annual performance period, with adjustments and exclusions as defined below. One hundred percent of the dollar value of care coordination payments is included in the per beneficiary cost of care calculation, except for the performance period which begins January 1, 2014, for which fifty percent of the dollar value of care coordination payments is included. As described in Section , beneficiaries not counted toward the minimum number of attributed beneficiaries for shared savings incentive payments will be excluded from the calculation of per beneficiary cost of care. A. The following costs are excluded from the calculation of per beneficiary cost of care: 1. All costs in excess of $100,000 for any individual beneficiary. 2. Behavioral health costs for beneficiaries with the most complex behavioral health needs. 3. Select costs associated with developmental disabilities (DD) services, identified on the basis of DD provider types. Section II-7

34 Patient-Centered Medical Home Section II 4. Select direct costs associated with Long-Term Support and Services (LTSS). 5. Select costs associated with nursing home fees, transportation fees, dental and vision. 6. Select neonatal costs. 7. Other costs as determined by DMS. Detailed information on specific exclusions are at A. The following adjustments are made to costs for calculation of per beneficiary cost of care: 1. Inpatient hospital claims will be adjusted to reflect a standard per diem. 2. Pharmacy costs will be adjusted to reflect rebates. 3. The per beneficiary cost of care for a shared savings entity is adjusted by the amount of supplemental payment incentives, both positive and negative, made under Episodes of Care for the beneficiaries attributed to practice(s) as described in Section Technical adjustments may be made by DHS and will be posted at If the shared savings entity s per beneficiary cost of care falls below the current performance period total cost of care floor, then the shared savings entity s per beneficiary cost of care will be set at the total cost of care floor, for purposes of calculating shared savings incentive payments. The 2014 cost of care floor is set at $1,400 and will increase by 1.5% each subsequent year Baseline and Benchmark Cost Calculations For the performance period that begins in January 2014, DMS will calculate a historical baseline per beneficiary cost of care for each shared savings entity. This shared savings entity-specific historical baseline will be calculated as a multi-year blended average of each shared savings entity s per beneficiary cost of care. DMS will calculate benchmark costs for each shared savings entity by applying a 2.6% benchmark trend to the entity s historical baseline per beneficiary cost of care. DMS may reevaluate the value of this benchmark trend if the annual, system-average per beneficiary cost of care growth rate differs significantly from a benchmark, to be specified by DMS. DMS will publish any modification to the benchmark trend at Shared Savings Incentive Payments Amounts A shared savings entity is eligible to receive a shared savings incentive payment that is the greater of: (A) a shared savings incentive payment for performance improvement; or (B) a shared savings incentive payment for absolute performance. A. Shared savings incentive payments for performance improvement are calculated as follows: 1. During each performance period, each shared savings entity s per beneficiary savings is calculated as: [benchmark cost for that performance period] [per beneficiary cost of care for that performance period]. 2. If the shared savings entity s per beneficiary cost of care falls below that entity s benchmark cost for that performance period by at least the minimum savings rate, only then may the shared savings entity be eligible for a shared savings incentive payment for performance improvement. 3. The per beneficiary shared savings incentive payment for performance improvement for which the shared savings entity may be eligible is calculated as follows: [per beneficiary savings for that performance period] * [shared savings entity s shared savings percentage for that performance period]. Section II-8

35 Patient-Centered Medical Home Section II 4. To establish shared savings percentages for a given performance period, DMS will compare the entity s previous year per beneficiary cost of care to the previous year s medium and high cost thresholds. For the performance period beginning January 2014, DMS will compare the entity s historical baseline cost to the base year thresholds to establish such entity s shared savings percentage. 5. If, in the previous performance period, a shared savings entity s per beneficiary cost of care was: a. Below the medium cost threshold, then the shared savings entity may receive 50% of per beneficiary savings created in the current performance period (i.e., the entity s shared savings percentage will be 50%); b. Between the medium and high cost thresholds, then the shared savings entity may receive 30% of per beneficiary savings created in the current performance period (i.e., the entity s shared savings percentage will be 30%); c. Above the high cost threshold, then the shared savings entity will not share in risk. Instead, the shared savings entity may receive 10% of per beneficiary savings created in the current performance period (i.e., the entity s shared savings percentage will be 10%). B. Shared savings incentive payments for absolute performance are calculated as follows: If the shared savings entity s per beneficiary cost of care falls below the current performance period medium cost threshold, then the shared savings entity may be eligible for a shared savings incentive payment for absolute performance. The per beneficiary shared savings incentive payment for absolute performance for which the entity may be eligible is calculated as follows: ([medium cost threshold for that performance period] [per beneficiary cost of care for that performance period]) * [50%]. The medium and high cost thresholds for 2014 are: A. Medium cost threshold: $2,032 B. High cost threshold: $2,718 These thresholds reflect an annual increase of 1.5% from the base year thresholds (base year medium cost threshold: $1,972; base year high cost threshold: $2,638) and will increase by 1.5% each subsequent year. The minimum savings rate is 2%. DMS may adjust this rate based on new research, empirical evidence or experience from initial provider experience with shared savings incentive payments. DMS will publish any such modification of the minimum savings rate at If the per beneficiary shared savings incentive payment for which the shared savings entity is eligible exceeds the shared savings incentive payment cap, expressed as 10% of the shared savings entity s benchmark cost for that performance period, the shared savings entity will be eligible for a per beneficiary shared savings incentive payment equal to 10% of its benchmark cost for that performance period. If the shared savings entity s per beneficiary cost of care falls above the current performance period high cost threshold, then the shared savings entity is not eligible for a shared savings incentive payment for that performance period. A shared savings entity s total shared savings incentive payment will be calculated as the per beneficiary shared savings incentive payment for which it is eligible multiplied by the number of attributed beneficiaries as described in Section , adjusted based on the amount of time beneficiaries were attributed to such entity s practice(s) and the risk profile of the attributed beneficiaries. Section II-9

36 Patient-Centered Medical Home Section II If participating practices have pooled their attributed beneficiaries together, then shared savings incentive payments will be allocated to those practices in proportion to the number of attributed beneficiaries that each practice contributed to such pool. A shared savings entity will not receive shared savings incentive payments unless it meets all the conditions described in Section DMS pays shared savings incentive payments on an annual basis for the most recently completed performance period and may withhold a portion of shared savings incentive payments to allow for final payment adjustment after a year of claims data is available. Final payment will include any adjustments required in order to account for all claims for dates of service within the performance period. If the final payment adjustment is negative, then DMS may recover the payment adjustment from the participating practice METRICS AND ACCOUNTABILITY FOR PAYMENT INCENTIVES Activities Tracked for Practice Support Using the provider portal, participating practices must complete and document the activities as described in the table below by the deadline indicated in the table. The reference point for the deadlines is the first day of the first calendar year in which the participating practice is enrolled in the PCMH program. Activity A. Identify top 10% of high-priority beneficiaries using: 1. DMS patient panel data that ranks beneficiaries by risk at beginning of performance period and/or 2. The practice s patient-centered assessment to determine which beneficiaries on this list are highpriority. Submit this list to DMS via the provider portal. B. Assess operations of practice and opportunities to improve and submit the assessment to DMS via the provider portal. C. Develop and record strategies to implement care coordination and practice transformation. Submit the strategies to DMS via the provider portal. D. Identify and reduce medical neighborhood barriers to coordinated care at the practice level. Describe barriers and approaches to overcome local challenges for coordinated care. Submit these descriptions of barriers and approaches to DMS via the provider portal. E. Make available 24/7 access to care. Provide telephone access to a live voice (e.g., an employee of the primary care physician or an answering service) or to an answering machine that immediately pages an on-call medical professional 24 hours per day, 7 days per week. The on-call professional must: Deadline 3 months and again 3 months after the start of each subsequent performance period (If such list is not submitted by this deadline, DMS will identify a default list of high-priority beneficiaries for the practice, based on risk scores). 6 months and again at 24 months 6 months 6 months 6 months 1. Provide information and instructions for treating Section II-10

37 Patient-Centered Medical Home Section II Activity emergency and non-emergency conditions, 2. Make appropriate referrals for non-emergency services and 3. Provide information regarding accessing other services and handling medical problems during hours the PCP s office is closed. Response to non-emergency after-hours calls must occur within 30 minutes. A call must be treated as an emergency if made under circumstances where a prudent layperson with an average knowledge of health care would reasonably believe that treatment is immediately necessary to prevent death or serious health impairment. 1. PCPs must make the after-hours telephone number known by all beneficiaries; posting the after-hours number on all public entries to each site; and including the after-hours number on answering machine greetings. 2. When employing an answering machine with recorded instructions for after-hours callers, PCPs should regularly check to ensure that the machine functions correctly and that the instructions are up to date. Practices must document completion of this activity by written report to DMS via the provider portal. F. Track same-day appointment requests by: Deadline 6 months 1. Using a tool to measure and monitor same-day appointment requests on a daily basis and 2. Recording fulfillment of same-day appointment requests. Practices must document compliance by written report to DMS via the provider portal. G. Establish processes that result in contact with beneficiaries who have not received preventive care. Practices must document compliance by written report to DMS via the provider portal. H. Complete a short survey related to beneficiaries ability to receive timely care, appointments and information from specialists, including Behavioral Health (BH) specialists. I. Invest in health care technology or tools that support practice transformation. Practices must document health care technology investments by written report to DMS via the provider portal. J. Join SHARE and be able to access inpatient discharge and transfer information. Practices must document compliance by written report to DMS via the provider portal. 12 months 12 months 12 months 12 months Section II-11

38 Patient-Centered Medical Home Section II Activity K. Incorporate e-prescribing into practice workflows. Practices must document compliance by written report to DMS via the provider portal. L. Use Electronic Health Record (EHR) for care coordination. The EHR adopted must be one that is certified by Office of the National Coordinator for Health Information Technology and is used to store care plans. Practices are to document completion of this activity via the provider portal. Deadline 18 months 24 months DMS may add, remove, or adjust these metrics or deadlines, including additions beyond 24 months, based on new research, empirical evidence or experience from initial metrics. DMS will publish such extension, addition, removal or adjustment at Metrics Tracked for Practice Support DMS assesses practices on the following metrics tracked for practice support starting on the first day of the first calendar year in which the participating practice is enrolled in the PCMH program and continuing through the full calendar year. To receive practice support, participating practices must meet a majority of targets listed below. Metric A. Percentage of high-priority beneficiaries (identified in Section ) whose care plan as contained in the medical record includes: 1. Documentation of a beneficiary s current problems; 2. Plan of care integrating contributions from health care team (including behavioral health professionals) and from the beneficiary; 3. Instructions for follow-up and 4. Assessment of progress to date. The care plan must be updated at least twice a year. B. Percentage of a practice s high priority beneficiaries seen by their attributed PCP at least twice in the past 12 months C. Percentage of beneficiaries who had an acute inpatient hospital stay and were seen by health care provider within 10 days of discharge D. Percentage of emergency visits categorized as nonemergent by the NYU ED algorithm Target for Calendar Year Beginning January 1, 2014 At least 70% At least 67% At least 33% Less than or equal to 50% DMS will publish targets for subsequent years, calibrated based on experience from targets initially set, at Such targets will escalate over time. DMS may add, remove, or adjust these metrics based on new research, empirical evidence or experience from initial metrics. Section II-12

39 Patient-Centered Medical Home Section II Accountability for Practice Support If a practice does not meet deadlines and targets for A) activities tracked for practice support and B) metrics tracked for practice support as described in Sections and , then the practice must remediate its performance to avoid suspension or termination of practice support. Practices must submit an improvement plan within 1 month of the date that a report provides notice that the practice failed to perform on the activities or metrics indicated above. A. With respect to activities tracked for practice support, practices must remediate performance before the end of the first full calendar quarter after the date the practice receives notice via the provider report that target(s) have not been met, except for activity A in Section where no such remediation time will be provided. B. With respect to metrics tracked for practice support, practices must remediate performance before the end of the second full calendar quarter after the date the practice receives notice via the provider report that target(s) have not been met. For purposes of remediation, performance is measured on the most recent four calendar quarters. If a practice fails to meet the deadlines or targets for activities and metrics tracked for practice support within this remediation time, then DMS will terminate practice support. DMS may resume practice support when the practice meets the deadlines or targets for activities and metrics tracked for practice support in effect for that quarter. DMS retains the right to confirm practices performance against deadlines and targets for activities and metrics tracked for practice support Quality Metrics Tracked for Shared Savings Incentive Payments DMS assesses the following quality metrics tracked for shared savings incentive payments according to the targets below. The quality metrics are assessed at the level of shared savings entity, except for the default pool. The quality metrics are assessed only if the entity or practice has at least 25 attributed beneficiaries in the category described for the majority of the performance period. To receive a shared savings incentive payment, the shared savings entity or practice must meet at least two-thirds of the quality metrics on which the entity or practice is assessed. Quality Metric A. Percentage of beneficiaries who turned 15 months old during the measurement year and had at least 4 wellchild visits during the first 15 months of life B. Percentage of beneficiaries 3-6 years of age who had one or more well-child visits during the measurement year C. Percentage of beneficiaries years of age who had one or more well-care visits during the measurement year D. Percentage of diabetes beneficiaries who complete annual HbA1C testing E. Percentage of beneficiaries prescribed appropriate asthma medications Target for Calendar year Beginning January 1, 2014 At least 67% At least 67% At least 40% At least 75% At least 70% F. Percentage of CHF beneficiaries on beta blockers At least 40% Section II-13

40 Patient-Centered Medical Home Section II Quality Metric G. Percentage of women ages who have had breast cancer screening in past 24 months H. Percentage of beneficiaries on thyroid drugs who had a TSH test in past 24 months I. Percentage of beneficiaries 6-12 years of age with an ambulatory prescription dispensed for ADHD medication that was prescribed by their PCMH, and who had one follow-up visit with their PCMH during the 30-day Initiation Phase. Target for Calendar year Beginning January 1, 2014 At least 50% At least 80% At least 25% DMS will publish targets for subsequent performance periods, calibrated based on experience from targets initially set, at DMS may add, remove or adjust these quality metrics based on new research, empirical evidence or experience from initial quality metrics Provider Reports DMS provides participating practices provider reports containing information about their practice performance on activities tracked for practice support, metrics tracked for practice support, quality metrics tracked for shared saving incentive payments and their per beneficiary cost of care via the provider portal COMPREHENSIVE PRIMARY CARE (CPC) INITIATIVE PRACTICE PARTICIPATION IN THE PCMH PROGRAM CPC Initiative Practice Participation Practices and physicians participating in the CPC initiative are not eligible to receive PCMH program practice support. Practices participating in the CPC initiative may receive PCMH program shared savings incentive payments if they: A. Enroll in the PCMH program; B. Meet the requirements for shared savings incentive payments, except that a practice participating in CPC need not maintain eligibility for practice support described in Section ; and C. Achieve all CPC milestones and measures on time. Section II-14

41 Care plan guidance document METRIC A: Percentage of high-priority beneficiaries (identified in Section ) whose care plan as contained in the medical record includes: 1. Documentation of current problem a. Each visit-related encounter document should include a list of current problems. 2. Plan of care integrating contributions from health care team (including behavioral health professionals) and from the beneficiary a. A visit-related encounter (or dated entry into a plan of care flowsheet or template) should include an entry that clearly summarizes the plan of care for the patient. Ideally, this should be a problem-based detail of the plan of care occurring twice during the 12-month timeframe. b. The problem assessment of diagnosis from the current problems could be included in the visit note in the plan section or as stand-alone documentation in a separate care plan template. c. If using separate documentation, make sure to include the date the plan is updated. d. The Plan or the Assessment and Plan section of the visit documentation must include statements of specific, problem-related plan information. i. For example, Plan: follow up on diabetes in four months with repeat A1C. e. Statements should include an approximate or absolute time and a follow-up item (e.g., lab, visit, referral, etc.). i. Example: Assessment and Plan 1. Type II Diabetes Mellitus: Improved after recent increase in insulin dosing. Continue current insulin and metformin doses. Refer to patient educator for help with diet. Follow up in the clinic in six months with Hgb A1C and microalbumin. 2. Essential Hypertension: Stable blood pressure, at target, no change in medications. Continue home blood pressure checks. Target is systolic <130. Patient will report blood pressure via secure messaging. AFMC CARE PLAN DOCUMENT JUNE 2014 PAGE 1 OF 3

42 Example of stand-alone care plan: DATE: 01/08/ /22/ /10/2014 PROBLEM 1 Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus PHASE OF CARE MEDICATIONS Elevated home blood sugars Glucophage XR 850mg Continued F/U office visit for disease management Glucophage XR 850mg Continued Care coordination visit and diabetes teaching Glucophage XR 850mg Continued DISCIPLINES PCP, Dietetics APN APN, Case Manager TESTS A1C: 9.6 A1C: 8.3 A1C: 7.5 STATUS Unstable; will recheck in three months, recheck A1C, dietetics: for healthy diet teaching Improved; recheck in three months, check A1C, Lipids, microalbumin and CMP for yearly labs Improving; await lab results, case manager will follow up for additional diabetic teaching 3. Instructions for follow-up a. Documentation mentioned in the visit/encounter of an existing future visit linked to a problem under management. i. For example, noting the patient has a future visit scheduled with a patient educator for diabetes management. b. Documentation could be contained within a completed assessment and plan would be acceptable, as would evidence in the chart. i. Example: Follow up in six months, patient is doing well. 4. Assessment of progress to date a. The encounter document should contain a problem-based assessment for all problems that were addressed during the visit. b. Clear documentation in the plan of care (EHR activity [telephone encounter/care plan update] or in a progress/visit note) identifying the course of a specific problem being tracked. c. Documentation should include reference to the problem stability. i. For example, problem is improving, deteriorating or stable. d. If the patient s problem is not clearly managed in a separate EHR activity (stand-alone care plan), then the Plan section of the encounter/visit documentation must clearly state or update the status of each problem. i. For example: Assessment 1. Type II diabetes, improved control after changes in insulin dosing. Hypertension that is at the treatment target. No changes in medications. Will draw lipid, CMP, A1C and complete a microalbumin in three months. 2. Type II diabetes mellitus: Improved after recent increase in insulin dosing. Will follow up in six months for A1C. 3. Essential hypertension: Stable blood pressure, at target, no change in medications. K+ level drawn today and results will be reported to patient via patient portal. AFMC CARE PLAN DOCUMENT JUNE 2014 PAGE 2 OF 3

43 NON-COMPLIANT PATIENTS: n If a patient misses a follow-up appointment, the clinic can utilize outreach to follow up. n A telephone note can be used to address and update the care plan, but it must contain a specific timeframe for followup to re-engage the patient. n If the patient is non-compliant and the clinic is utilizing outreach to follow up, there should be documentation showing a good faith effort has been made to reach the patient and reschedule them. THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. MP2-PCMH.BRO.3-7/14 AFMC CARE PLAN DOCUMENT JUNE 2014 PAGE 3 OF 3

44 06/10/14 SUBJECTIVE: This is a 6-year-old male who comes in rechecking his ADHD medicines, accompanied by both parents. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication. Family dynamics are good and both parents provide input and support in his treatment. PAST HISTORY: Reviewed from appointment on 01/16/2014. CURRENT MEDICATIONS: He is on Adderall XR 10 mg once daily. ALLERGIES: To medicines are none. FAMILY AND SOCIAL HISTORY: Reviewed from appointment on 01/16/2014. REVIEW OF SYSTEMS: He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay. Review of systems is otherwise negative. OBJECTIVE: Weight is 46.5 pounds, which is down just a little bit from his appointment last month. He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room. Physical exam itself was deferred today because he has otherwise been very healthy. ASSESSMENT: At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall. PLAN: Discussed with mother two options. Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose. As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer. So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon. Will ask for educator feedback on child progress through clinic feedback form. Mother is to watch his diet. We would like to recheck his weight if he is doing very well, in two months. But if there are any problems, especially in the morning then we would do the Ritalin LA. Mother understands and will call if there are problems. Approximately 25 minutes spent with patient, all in discussion.

45 CC: F/U HTN Vital: 160/96 BP; HR 72, RR 16, WT 216, HT yo Caucasian retired male schoolteacher presents for 6 mo follow up of HTN. Patient maintains home BP log when he can remember, although he did not bring this into the visit today. He recalls that his BPs run in the 130 s systolic and 80 s diastolic. Todays BP s 160/96, which is higher than home readings. He has had no orthostatic sc s, no chest pain, dyspnea, orthopnea, edema, headaches, dizziness, visual problems, joint pain, muscle aches, or depressive sx s. He doesn t feel that he has undue stress in his life and feels generally happy with his relationships and retirement. He has a relatively poor diet with frequent fast foods and has not been able to lose weight as desired, not attention to salt restriction. He has been an ex-smoker for 30y, occasional ETOH use. No personal hx or sx of CVA or TIA, diabetes or peripheral vascular disease, but he has had an angioplasty 10y ago for CAD, and states he feels pretty good overall. CAD appears to be stable, has a follow up appointment with cardiologist on 07/02/2014. He does have some increased urinary frequency with the HCTZ but understands that this is normal. Medications: HCTZ 25mg 1qd (on for 1 Year) Atenolol 25mg 1 qd (added 6 mo ago to attempt to improve BP control) Lipitor 10mg qd (for CAD) ASA 81mg qd O: Moderately overweight with central obesity, waist circumference today is 42inches. HEENT: Fundi shows moderate asvd changes, no hems or exudates, discs sharp, carotid pulses full and equal, no bruits, no JVD Chest: clear to auscultation. No rales, normal breath sounds Heart: RR, PMI in normal location and no heave or evidence of cardiomegaly, normal heart sounds, no murmur or gallop ABD: no bruits over abdominal vessels, no aortic widening, no hepatosplenomegaly Extremities: good / equal peripheral pulses, radial, post tibial and dorsalis ped all palp., no trphic skin changes Cognitive Function and affect: normal, Mini Mental status, normal Assessment: Hypertension not adequately controlled on present medications. Coronary Artery Disease S/P angioplasty Dyslipidemia Obestiy

46 Plan: Labs: CMP, Lipid, Renal Panel to be drawn today Discussed the importance of BP control and compliance with medication. F/U in 1 week for BP recheck. He will bring home BP logs to next visit along with home BP monitor for comparison. At that time we will discuss lab results and determine if additional workup for other etiologies of HTN is needed, as well as, consider adding Rx if control remains inadequate. Coronary Artery Disease is followed by cardiologist, documentation from cardiologist identifies most recent EKG was normal and he is to follow up in 6 months. Dyslipidemia and Obesity: Discussed the need for healthy lifestyle changes including diet and exercise. Referral to dietician for weight loss and heart healthy diet. Care team member will follow up by phone after referral.

47 Activities Tracked for Practice Support Using the provider portal, participating practices must complete and document the activities as described in the table below by the deadline indicated in the table. The reference point for the deadlines is the first day of the first calendar year in which the participating practice is enrolled in the PCMH program. Activity A. Identify top 10% of high-priority beneficiaries using: 1. DMS patient panel data that ranks beneficiaries by risk at beginning of performance period and/or 2. The practice s patient-centered assessment to determine which beneficiaries on this list are highpriority. Submit this list to DMS via the provider portal. B. Assess operations of practice and opportunities to improve and submit the assessment to DMS via the provider portal. C. Develop and record strategies to implement care coordination and practice transformation. Submit the strategies to DMS via the provider portal. D. Identify and reduce medical neighborhood barriers to coordinated care at the practice level. Describe barriers and approaches to overcome local challenges for coordinated care. Submit these descriptions of barriers and approaches to DMS via the provider portal. E. Make available 24/7 access to care. Provide telephone access to a live voice (e.g., an employee of the primary care physician or an answering service) or to an answering machine that immediately pages an on-call medical professional 24 hours per day, 7 days per week. The on-call professional must: 1. Provide information and instructions for treating emergency and non-emergency conditions, 2. Make appropriate referrals for non-emergency services and 3. Provide information regarding accessing other services and handling medical problems during hours the PCP s office is closed. Response to non-emergency after-hours calls must occur within 30 minutes. A call must be treated as an emergency if made under circumstances where a prudent layperson with an average knowledge of health care would reasonably believe that treatment is immediately necessary to prevent death or serious health impairment. Deadline 3 months and again 3 months after the start of each subsequent performance period (If such list is not submitted by this deadline, DMS will identify a default list of high-priority beneficiaries for the practice, based on risk scores). 6 months and again at 24 months 6 months 6 months 6 months

48 Activity 1. PCPs must make the after-hours telephone number known by all beneficiaries; posting the after-hours number on all public entries to each site; and including the after-hours number on answering machine greetings. 2. When employing an answering machine with recorded instructions for after-hours callers, PCPs should regularly check to ensure that the machine functions correctly and that the instructions are up to date. Practices must document completion of this activity by written report to DMS via the provider portal. F. Track same-day appointment requests by: 1. Using a tool to measure and monitor same-day appointment requests on a daily basis and 2. Recording fulfillment of same-day appointment requests. Practices must document compliance by written report to DMS via the provider portal. G. Establish processes that result in contact with beneficiaries who have not received preventive care. Practices must document compliance by written report to DMS via the provider portal. H. Complete a short survey related to beneficiaries ability to receive timely care, appointments and information from specialists, including Behavioral Health (BH) specialists. I. Invest in health care technology or tools that support practice transformation. Practices must document health care technology investments by written report to DMS via the provider portal. J. Join SHARE and be able to access inpatient discharge and transfer information. Practices must document compliance by written report to DMS via the provider portal. K. Incorporate e-prescribing into practice workflows. Practices must document compliance by written report to DMS via the provider portal. Deadline 6 months 12 months 12 months 12 months 12 months 18 months

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55 Here for Arkansas. you. Here for Health care in Arkansas is changing. To keep up, your practice needs expert guidance that keeps your business running smoothly. That s where AFMC s practice transformation team comes in. The same company that has spent more than 40 years helping Arkansas practices grow and thrive is now helping you with your PCMH needs. Whether you are just getting started becoming a PCMH or you need help completing the initiative, our Arkansas-based experts are ready to get your practice where it needs to be. Best of all, it s free to you! Our multidisciplinary team has a personal stake in your success. We live in your community and work in your county. We are committed to your success. Sign up with AFMC practice transformation at afmc.org/pt. Benefits of AFMC Practice Transformation The only practice transformation team based in Arkansas Guaranteed monthly onsite visits A tailored plan to monitor activities, metrics and quality to ensure PCMH success Guaranteed a minimum of 30 hours of support* (up to 65 hours for larger practices) An in-depth assessment of your practice s needs Virtual meetings and learning sessions Your personal road map, customized to help transform your practice into a PCMH *Minimum 300 beneficiaries served

56 AFMC is at the center of health care and practice transformation in Arkansas! VM QI Value Modifier ACT Arkansas Clinical Transformation Project Quality Improvement CDC PQRS Enhance Academic Detailing to Increase Immunization Recall Rate AFMC Physician Quality Reporting System CPCi Comprehensive Primary Care Initiative PCMH Patient Centered Medical Home APII Arkansas Payment Improvement Initiative HIE MU Meaningful Use HIT Health Information Technology Health Insurance Exchange To sign up for AFMC practice transformation, visit afmc.org/pt, us at or call We look forward to working with you! THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) PURSUANT TO CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENT PRESENTED DOES NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. DOCUMENTS AND FORMS PROVIDED BY AFMC ARE FOR PARTICIPANTS AND MEMBERS ONLY. AFMC MAY MAKE CUSTOMIZATIONS TO THE DOCUMENT OR FORM THAT APPLIES ONLY TO THE PARTICIPANT OR MEMBER FOR WHOM IT HAS BEEN PROVIDED. FOR SECURITY PURPOSES AND TO ENSURE THAT EACH PARTICIPANT AND MEMBER IS RECEIVING THE APPROPRIATE FORMS AND DOCUMENTS, RETRANSMITTING, SHARING OR DISSEMINATING WITHOUT THE EXPRESS WRITTEN CONSENT OF AFMC IS STRICTLY PROHIBITED. MP2-PCMH-PT.FLY,2/15

57 AFMC PCMH Practice Transformation Agreement Form (2015) Welcome to the Arkansas Foundation for Medical Care s PCMH practice transformation family! You re about to start your personal practice transformation journey with the best multidisciplinary team in Arkansas. Best of all, it s free for you! To get started, please enter in your information below. If you want more information about practice transformation, visit afmc.org/pt. 1 MEDICAID PCMH ENROLLED NAME MEDICAID BILLING ID NUMBER 2 3 NUMBER OF MEDICAID BENEFICIARIES SERVED BY YOUR PCMH 4 5 DATE ENROLLED IN PCMH PROGRAM NUMBER OF FACILITIES OR PRACTICES INCLUDED IN YOUR PCMH 6 NAME AND ADDRESS OF EACH PCMH LOCATION 1. NAME ADDRESS 2. NAME ADDRESS 3. NAME ADDRESS 4. NAME ADDRESS 7 PCMH LEAD POINT OF CONTACT NAME TITLE ADDRESS PHONE IS THIS A CELL PHONE? n YES n NO PREFERRED METHOD OF CONTACT? n n PHONE PRACTICE WHERE THIS CONTACT WORKS 7A IS THIS CONTACT THE PCMH LEAD FOR ALL PRACTICE LOCATIONS? n YES n NO (IF YES, CONTINUE TO THE END OF THE AGREEMENT FORM) CONTINUED, NEXT PAGE CONFIDENTIALITY STATEMENT Under federal regulations, a healthcare quality improvement project is considered a quality review study as defined in 42 CFR Section (b) as being an assessment, conducted by or for AFMC, of a patient care problem for the purpose of improving patient care through peer analysis, intervention, resolution of the problem and follow-up. Further, federal regulations at 42 CFR Section protect the identities of individual patients, practitioners, and institutions that participate in such studies, and prohibits, with few exceptions, AFMC from disclosing any specific information about their work on quality review studies. AFMC cannot disclose information or data about participants in a quality review study to any party unless the information identifies only physicians, other practitioners, or practices, and those parties must consent to the release of information.

58 7B PCMH LEAD POINT OF CONTACT FOR OTHER LOCATIONS NAME TITLE ADDRESS PHONE IS THIS A CELL PHONE? n YES n NO PREFERRED METHOD OF CONTACT? n n PHONE PRACTICE WHERE THIS CONTACT WORKS 7C PCMH LEAD POINT OF CONTACT FOR OTHER LOCATIONS NAME TITLE ADDRESS PHONE IS THIS A CELL PHONE? n YES n NO PREFERRED METHOD OF CONTACT? n n PHONE PRACTICE WHERE THIS CONTACT WORKS 7D PCMH LEAD POINT OF CONTACT FOR OTHER LOCATIONS NAME TITLE ADDRESS PHONE IS THIS A CELL PHONE? n YES n NO PREFERRED METHOD OF CONTACT? n n PHONE PRACTICE WHERE THIS CONTACT WORKS AFMC PCMH Practice Transformation Agreement By signing, you agree to work with the AFMC PCMH practice transformation team according to terms set forth. Agreement is effective upon signing below, through Dec. 31, Only one signature is required per PCMH, regardless of the number of locations. This PCMH agreement will automatically renew each calendar year unless the PCMH opts out. SIGNATURE PRINT NAME DATE NPI # PRINT TITLE If you fill out the form by hand, please scan and to [email protected] or fax it to Questions? Please call or [email protected]. We look forward to working with you! THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) PURSUANT TO CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENT PRESENTED DOES NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. DOCUMENTS AND FORMS PROVIDED BY AFMC ARE FOR PARTICIPANTS AND MEMBERS ONLY. AFMC MAY MAKE CUSTOMIZATIONS TO THE DOCUMENT OR FORM THAT APPLIES ONLY TO THE PARTICIPANT OR MEMBER FOR WHOM IT HAS BEEN PROVIDED. FOR SECURITY PURPOSES AND TO ENSURE THAT EACH PARTICIPANT AND MEMBER IS RECEIVING THE APPROPRIATE FORMS AND DOCUMENTS, RETRANSMITTING, SHARING OR DISSEMINATING WITHOUT THE EXPRESS WRITTEN CONSENT OF AFMC IS STRICTLY PROHIBITED. MP2-PCMHPT.ENR.FRM,2/15

59 AFMC PCMH Practice Transformation Agreement for Services Form (2015) (PCMH NAME) agrees to work with the Arkansas Foundation for Medical Care (AFMC) as its practice transformation DHS contracted vendor for the Arkansas Medicaid Patient Centered Medical Home Initiative. Under its contract with the Arkansas Department of Human Services, Division of Medical Services, AFMC is charged with providing support to enable practices to integrate approaches, tools and infrastructure needed to improve performance and realize goals of the Patient Centered Medical Home. The information outlined below explains the responsibilities of the PCMH practice and AFMC. The effective date of the consent agreement shall commence on the date signed below through December 31 of the current year. Pursuant to DMS contract with AFMC as a practice transformation vendor, this agreement will renew annually unless PCMH chooses to discontinue participation. As part of this agreement, I commit my organization s full participation in this initiative and will work to achieve a designated level of improvement. The practice agrees to the following: 1. Identify an appropriate PCMH project team (which will have a designated team lead) that shall have sufficient time designated to work on PCMH goals 2. Communicate with AFMC PT team on an agreed-upon schedule, identify methods to evaluate progress and identify/address any barriers to progress regarding PCMH goals 3. Follow implementation plan, complete required activities and meet agreed-upon project goals 4. Maintain documentation of activities and metrics as defined by PT team 5. Monitor data for improvement and provide AFMC PT facilitator with data, at least quarterly 6. Participate in learning collaborative activities and share best practices AFMC s PCMH Practice Transformation team will provide support at no cost to the PCMH as identified in section of the Patient-Centered Medical Home Manual and as part of this agreement, commits to provide: 1. A PCMH readiness assessment and tailored implementation plan 2. Face-to-face visits a minimum of once per month 3. A minimum of 30 hours of support for practices with at least 300 beneficiaries (up to 65 hours of support of large practices, which are those consisting of five or more primary care providers or having three or more participating locations) 4. Virtual meetings and learning sessions 5. A PCMH road map (which will assist PCMHs in tracking and monitoring achievement of activities and metrics) 6. Online and collaborative learning community (members-only access to monthly, quarterly webinars and educational events/tools along with collaborative space for members) By affixing my signature, I agree to adhere to the responsibilities of the practice and abide by the above terms. SIGNATURE OF AUTHORIZED PRACTICE/ HEALTH CARE FACILITY REPRESENTATIVE PRINT PRACTICE NAME PRINT NAME INTERNAL USE ONLY SIGNATURE OF AFMC PCMHPT REPRESENTATIVE TITLE If you fill out the form by hand, please scan and to [email protected] or fax it to Questions? Please call or [email protected]. THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) PURSUANT TO CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENT PRESENTED DOES NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. DOCUMENTS AND FORMS PROVIDED BY AFMC ARE FOR PARTICIPANTS AND MEMBERS ONLY. AFMC MAY MAKE CUSTOMIZATIONS TO THE DOCUMENT OR FORM THAT APPLIES ONLY TO THE PARTICIPANT OR MEMBER FOR WHOM IT HAS BEEN PROVIDED. FOR SECURITY PURPOSES AND TO ENSURE THAT EACH PARTICIPANT AND MEMBER IS RECEIVING THE APPROPRIATE FORMS AND DOCUMENTS, RETRANSMITTING, SHARING OR DISSEMINATING WITHOUT THE EXPRESS WRITTEN CONSENT OF AFMC IS STRICTLY PROHIBITED. MP2-PCMHPT.ENR.AFSFRM,2/15 DATE DATE DATE RETURNED TO AFMC

60

61 AMII PCP Reports Once a Medicaid Provider has logged into the portal successfully, if the provider is a PCP, they will have available VIEW AMII REPORTS under Available Tools in the left hand box. Click this link to proceed to the AMII logon page.

62 AMII Registration Page The following is the AMII registration page. If this is the first time the PCP has accessed the AMII reports, it will ask them for the following information. Please read the disclaimer in the text box. They must check the box I accept terms and conditions before the create account button is activated.

63 Upon successful registration, the PCP will receive the following page. Click here to logon to AMII reports.

64 AMII Login Page The PCP is then redirected to the logon page where the PCP will now enter their user name (Medicaid provider ID used to log into the portal with) and the password created from the registration. If the PCP is entering the logon page outside of initial registration, your Medicaid ID will be plugged. Click log on to continue.

65

66 After successful login, the PCP will be directed to the Infoview home page. To access the AMII reports the PCP must navigate to the Documents List using either of the two red highlighted links. Please note that the PCP may change their preferences so that every time they login, they will automatically be redirected to this page. This can be accomplished by selecting either of the two blue highlighted links and follow the instructions on the next page.

67 Changing Preferences To change the PCP s preferences so that you are always taken to the AMII reports page after logging in: After selecting Preferences on the Infoview home page, expand the General section. Select the radio button next to Folder: and then click Browse Folder. Select the AMII folder located under Public Folders and then click on OK.

68 AMII Report Retrieval After selecting Document List, the PCP must navigate to the AMII folder located under Public Folders to gain access to the AMII reports. The five reports seen here are those that are available to the PCP. Simply double click the title to access the report for the Medicaid ID that is in the logon credentials.

69 Examples of Filtering The PCP may filter on any field within the AMII report retrieved. The following instructions are using a dummy sample report.

70 The Show/Hide Report Filter Toolbar needs to be activated by clicking it. When activated, it will show as if it were a button that is depressed.

71 When you activate the Show/Hide Report Filter Toolbar an area above the reports appear. You can now drag the objects to this space on which to filter. In this example, we are dragging NUM EOB to the red circle area. Drag these items to the area in the red oval.

72 Here you now see that the EOB number is available on the Show/Hide Report Filter Toolbar and a dropdown box is available to filter the data.

73 Drop down box showing all the filter options for EOB.

74

75 Query filtered for EOB 004.

76 Examples of downloading to PDF or Excel

77 To export the PCP report results to an Excel Spreadsheet or PDF, click on the down arrow of the save icon which is the diskette picture. Choose Save to my computer as either an Excel or PDF document. The PCP will then be prompted to Open or Save.

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79 If the PCP chooses Save, you will be prompted to choose a file location: If the PCP chooses Open, the query results will open in the selected application i.e. Excel or PDF.

80 ARKIDS Full Preventive Health Screen Billing Procedures 2009 PROCEDURE CODE BY AGE MODIFIERS NEWBORN <1 YEAR 1-4 YEARS 5-11 YEARS YEARS MODIFIER 1 MODIFIER 2 ARKIDS A - EPSDT SCREEN New Patient EP U1 Established Patient EP U2 * ARKids A Must Choose Special Program Code 01 Newborn in Hospital Initial hospital/birthing center care/normal newborn Initial hospital/birthing center normal NBadmitted/discharged same date of service EP UA Newborn in Other Setting Initial care normal newborn other than hospital/birthing center EP UA ARKIDS B - PREVENTIVE HEALTH SCREEN New Patient Established Patient NO MODIFIERS FOR ARKIDS B Newborn in Hospital Initial hospital/birthing center care/normal newborn Initial hospital /birthing center care, normal NB admitted/discharged same date of service (Newborn Only) UA Newborn in Other Setting Initial care normal newborn other than hospital/birthing center UA Newborn procedure codes pay $ while all other listed codes pay $56.41.

81 ARKANSAS MEDICAID CHILD HEALTH SERVICES (EPSDT) FEE SCHEDULE This fee schedule does not address the various coverage limitations routinely applied by Arkansas Medicaid before final payment is determined (e.g., beneficiary and provider eligibility, benefit limits, billing instructions, frequency of services, third party liability, age restrictions, prior authorization, co-payments/coinsurance where applicable, etc.). Procedure codes and/or fee schedule amounts listed do not guarantee payment, coverage or amount allowed. Although every effort is made to ensure the accuracy of this information, discrepancies and time lag may occur. All information may be changed or updated at any time to correct a discrepancy and/or error. The reimbursement rates reflected in this fee schedule are in effect as of the date of this report. The reimbursement rate made on a claim will depend on the date of service since our reimbursement rates are date of service effective. The fee schedule reflects only procedure codes that are currently payable. Any procedure code reflecting a Medicaid maximum of $0.00 is manually priced. This fee schedule only reflects the EPSDT screenings and the Vaccine for Children immunizations. You will need to access the applicable fee schedule for all other services covered for the EPSDT program. Please note that Arkansas Medicaid will reimburse the lesser of the amount billed or the Medicaid maximum. For a full explanation of the procedure codes/modifiers, refer to the information in your provider manuals. Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright 2009 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Run Date 5/18/12 Procedure Code TOS Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $9.56

82 EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP ZZZ $ EP ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $56.41

83 EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP ZZZ $ EP UA ZZZ $ EP UA ZZZ $ EP UA ZZZ $ V EP ZZZ $12.02 V EP ZZZ $344.75

84 EPSDT Manual: Foster Care Intake Physical Examination in the EPSDT Program Arkansas Medicaid beneficiaries entering the Arkansas foster care system are required to receive an intake physical examination within the first seventy two (72) hours. If the EPSDT provider who performs the screening is not the beneficiary s PCP, the intake physical examination should be billed with procedure codes and modifiers EP and H9. Billing with these procedure codes and modifiers will allow the claim to be submitted for payment without a referral from the beneficiary s PCP and will alert the system not to count the screen toward the beneficiary s yearly EPSDT periodic complete medical screening limits. If the EPSDT provider who performs the screen is the beneficiary s PCP, the intake physical exam should be billed with procedure codes and modifiers EP and H9. Billing with these procedure codes and modifiers will allow the claim to be submitted for payment and will not count toward the beneficiary s yearly EPSDT periodic complete medical screening limits. Procedure codes and , in conjunction with the EP and H9 modifiers, are to be used only for the required intake physical examination for Medicaid beneficiaries in the Arkansas foster care system.

85 Screenings and Sick Visits Child Health Services (EPSDT) Screenings and Sick Visits Screenings performed on the same date of service as an office visit for treatment of an acute or chronic condition may be billed as a periodic Child Health Services (EPSDT) screening, electronically or on paper using the CMS-1500 claim form. Effective for dates of service on and after May 1, 2006, a Child Health Services (EPSDT) screening performed during an office visit for treatment of an acute or chronic condition may be billed as a separate visit for the same date of service using a CPT evaluation and management procedure code. Do not use modifiers on the sick visit procedure code. The visit must be billed electronically, or on paper using a separate CMS-1500 form. View a CMS-1500 sample form Completion of the CMS-1500 Claim Form Required Reason Code location: 24H H. EPSDT/Family Plan EPSDT Reason Codes are required for EPSDT services. Please enter the appropriate 2 byte reason code in the upper shaded part of the detail line. AV Available Not Used (patient refused referral) NU Not Used (used when no EPSDT patient referral was given) S2 Under Treatment (patient is currently under treatment for referred diagnostic or corrective health problem) ST New Service Requested (Referral to another provider for diagnostic or corrective treatment/scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service, not including dental referrals.) Family Planning Indicator is not applicable for this claim type. See Sections of the EPSDT manual for specific EPSDT billing instructions. PLEASE REFER TO OFFICIAL NOTICE DATED: December 1, CMS-1500 Replaces DMS-694 for EPSDT Screenings or Services

86 PROVIDED BY THE Arkansas Health Care Independence Program MyIndyCard Frequently Asked Questions (FAQs) for Providers ENROLLEE ELIGIBILITY AND PARTICIPATION Who is eligible to participate in the MyIndyCard Program? Participants in the Health Care Independence Program (Private Option) who are enrolled in one of the five health plans listed below: QualChoice Life and Health Silver AmBetter Balanced Care 2 QualChoice of Arkansas Classic Silver Arkansas BlueCross and BlueShield Silver 3500 Arkansas BlueCross and BlueShield 2000, Multi-State Until July 2015, only those in the percent range of the federal poverty level (FPL) will be issued cards. Those in the percent FPL range will not be in the MyIndyCard program, but are being educated on how health insurance and the Private Option work, in anticipation of providing MyIndyCards to them in July. When is the MyIndyCard in effect? Cards have already been sent to participants and can be used as soon as they are activated. To activate their card, participants can go to or call MyIndyCard customer support at Will the insurance card indicate if the participant has a MyIndyCard? No, the primary insurance card will not indicate specifically if the participant has a MyIndyCard. However, if participants are covered by one of the silver plans listed below, he/she is eligible for a card. QualChoice Life and Health Silver AmBetter Balanced Care 2 QualChoice of Arkansas Classic Silver Arkansas BlueCross and BlueShield Silver 3500 Arkansas BlueCross and BlueShield 2000, Multi-State Participants must, however, obtain and activate the card, and make contributions during the previous month to be eligible for co-pay reimbursement during the current month. F1214 CONTINUED, NEXT PAGE

87 How will providers know who should have a MyIndyCard if they do not present it at the time of service? Those who present insurance cards from one of the five private option plans listed above, that also show the need for co-pays, should have a MyIndyCard. If a person appears to be eligible, and does not have a card, or has a card and has not activated it, they can activate their card or request another card by calling MyIndyCard Customer Service at Is there anything on the AHIN or Medicaid websites that indicates whether the patient has a MyIndyCard if the patient doesn t have the card with him or her? No. But you or the patient can call MyIndyCard Customer Service at to find out. Will one card cover everyone in a family, including children? No. MyIndyCard is for individuals between the ages of 19 and 64. If spouses or adult children in the same household qualify, each will have a separate card. almost certainly save them money on co-pays. If they make their monthly contribution, they are covered for the entire month for all co-pays. One inpatient stay has a co-pay of $140 per day, which they would have to pay out of pocket if they opt out of receiving a MyIndyCard. Co-pays for prescriptions are either $4 or $8, so if they have prescriptions, it would be a direct benefit also for them to have the MyIndyCard. Is it mandatory for all insured persons to participate in the program or is it by choice? The MyIndyCard is not mandatory, but it should be encouraged as those participating in the insurance plans that offer MyIndyCard are required to pay co-pays, and MyIndyCard effectively pays those co-pays, up to a yearly max of $604, provided participants have made their monthly contribution to the MyIndyCard. Is $15 the maximum amount they are required to pay per month? A participant s monthly contribution is based on income, but yes, $15 per month would be the most that any participant would be required to contribute to keep his or her MyIndyCard active. Do the consumers have to activate their cards or can they choose to pay their co-pays out-of-pocket like last year? Participants are not required to activate their card, but they should be encouraged to do so. The card is a significant benefit that will CONTINUED, NEXT PAGE

88 WHAT MYINDYCARD COVERS Will MyIndyCard pay the co-pay for an X-ray at a chiropractic clinic? Participants pay for an x-ray at a chiropractic clinic. Can this be used for routine vision exams? No. Dental and vision are not covered. Can participants use the MyIndyCard to pay on a balance for a December 2014 visit? No. MyIndyCard only pays co-pays for qualified participants who are current on their monthly contributions to the plan. Will there be an emergency room co-pay? No. Emergency room visits are not covered under MyIndyCard. CO-PAYS AND LIMITS If primary insurance co-pay states $20 for durable medical equipment, can we only charge $4 for the co-pay with this card? Correct. The agreed upon co-pay for durable medical equipment with these plans is only $4. That is the only amount that can be charged for that service using the MyIndyCard. Will the co-pay on the participant s insurance card be the same as the MyIndyCard? Yes. Is there a fee schedule that shows what insurance pays after the patient s co-pay, or will it be the same fee schedule as BlueCross and BlueShield? The fee schedule will be that which was previously agreed to by each particular insurance carrier, in this case, BlueCross and BlueShield. What does the card cover at specialty clinics? $10 is the maximum co-pay amount that preferred clinics can charge. CONTINUED, NEXT PAGE

89 Is there a limit on how many co-pays can be paid in a specific day or month? There is no limit to the number of co-pays that can be paid in a covered day, or month, as long as the participant has made their monthly contribution in the month prior. The only limit is the total dollar amount that can be paid out, which is $604. If/when a person exceeds the maximum amount of $604; he or she will be moved to a different plan. PARTICIPATING INSURANCE CARRIERS Will patients have an insurance card in addition to the MyIndyCard? They should have their insurance card. In the event that they do not, the provider will need to contact the insurance carrier to get other information related to their plan. Was the MyIndyCard issued to all carriers? No. Only those carrier plans that are participating in the Private Option, and within those plans, only to those patients in the percent federal poverty level range. Those plans are: QualChoice Life and Health Silver AmBetter Balanced Care 2 QualChoice of Arkansas Classic Silver Arkansas BlueCross and BlueShield Silver 3500 Arkansas BlueCross and BlueShield 2000, Multi-State PROCESSING MYINDYCARD FOR PAYMENT Can the card number be keyed in if the provider s office doesn t have a card swipe machine? Yes. If a provider does not accept credit cards, and the patient has to pay the co-pay, how do they get reimbursed? The patient should contact MyIndyCard Customer service for details at MyIndyCard.org, or call If the patient uses a pharmacy out of town and has medications mailed to them, how can they be reimbursed if their active MyIndyCard cannot be swiped? They can call in their MyIndyCard number, just like any other credit card, or mail their receipt to DataPath Administrative Service at the address listed on MyIndyCard.org. For more information, contact MyIndyCard customer service at MyIndyCard.org, or call CONTINUED, NEXT PAGE

90 Our facility accepts credit card payments over the phone. If a patient calls and provides a MasterCard number for payment, how do we know it is a MyIndyCard, or for the particular patient in question? Any form of payment can be used to pay the co-pay. When taking the payment, the name on the card should match that of the person receiving service. If the patient fails to make the contributions, will the MyIndyCard be declined? Yes. Participants must have made their contribution during the previous month to be covered in the current month. RECEIVING PAYMENT FOR MYINDYCARD How will providers get their money from DataPath? Providers will only be reimbursed for co-pays, which will be processed electronically if the provider accepts credit cards. All other fees will be collected, through their insurance carrier. Do you have to sign up with DataPath to get your payments? No. Payments for co-pays are adjudicated based on participation in one of the QHPs participating in the program. QualChoice Life and Health Silver AmBetter Balanced Care 2 QualChoice of Arkansas Classic Silver Arkansas BlueCross and BlueShield Silver 3500 Arkansas BlueCross and BlueShield 2000, Multi-State So after the first 60 days are paid, and participants never make a contribution afterwards, does the money paid to the provider get taken back? No. Whatever was paid to the provider was for services rendered during a period when the participant was covered. If the provider should choose to see the participant while his or her card is inactive after not making their contributions, it will be up to the provider to collect the co-pay at the point of service. CONTINUED, NEXT PAGE

91 MYINDYCARD PROVIDER WEBINAR Will the MyIndyCard provider webinar presentation be available electronically? Yes, the slide deck, recorded webinar and FAQs will be posted to MyIndyCard.org under the provider section. Many other downloadable resources are also available on the Resources section of MyIndyCard.org. THE ARKANSAS HEALTH CARE INDEPENDENCE PROGRAM IS ADMINISTERED BY THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. REVISED JAN.-2015

92 How Do I Make MyIndyCard Active? Visit to make your card active. You also can call and follow the steps to activate MyIndyCard. When your card is activated, you can use it at your doctor s office or pharmacy. Problems with MyIndyCard? Damaged or destroyed? Card not working? Need to get a new card? Any other questions? or visit Say hello to the Pocket User Guide PROVIDED BY THE THE ARKANSAS HEALTH CARE INDEPENDENCE PROGRAM IS ADMINISTERED BY THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. REVISED DEC QG1214

93 Where Can I Make Payments? Pay online at: Mail a check, money order or cashier s check to: MyIndyCard P.O. Box 9664 Conway, AR Make sure your account number is on the check or money order. Do not send cash. Where Can I Use MyIndyCard? MyIndyCard pays for your part of the cost of visiting the doctor. This is called your co-pay. MyIndyCard takes care of your co-pay at these places, as long as they are in-network: Doctors offices Other medical places like hospitals or clinics, physical therapy, labs, and X-rays Pharmacies, but only for prescriptions What Do I Need to Pay MyIndyCard? To make a payment, you need your account number and payment amount. This will be in your monthly statement and at MyIndyCard.org. Write them down here to help you remember. MyIndyCard Account Number is: MyIndyCard Payment is:

94 For More Information Is the card damaged or destroyed? Is the card not working or declined? Does the cardholder need a new card? Any other questions? or visit PC1214

95 THE ARKANSAS HEALTH CARE INDEPENDENCE PROGRAM IS ADMINISTERED BY THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. REVISED DEC.-2014

96 Say hello to the MyIndyCard User Guide PROVIDED BY THE #

97 Table of Contents Introduction... 1 Health Care Independence Program... 2 Health Independence Accounts... 3 Using MyIndyCard... 5 MyIndyCard Statements... 8 Making Payments...12 Penalties Words to Know... 15

98 Introduction Congratulations on getting MyIndyCard! MyIndyCard will help you get the health care you need. This guide will tell you: How to use MyIndyCard Where to use it How to make payments Who to contact if you have a problem You are not required to participate in the MyIndyCard program. If you do not participate, you will have to pay your co-pay on your own. MyIndyCard is a benefit of the Private Option. It s up to you if you want to participate. Before telling you how to use your card, let s talk about the program. 1

99 Health Care Independence Program MyIndyCard is a part of the Arkansas Health Care Independence Program (also called the Private Option). The Health Care Independence Program is an Arkansas program that started in January The federal and state governments pay for the program. The money goes to help people buy health insurance. 2

100 Health Independence Accounts (HIA) In 2015, Arkansas is adding a new feature to the Health Care Independence Program. This feature is called a Health Independence Account (HIA). You and others in this program will pay a small amount to help cover health care costs. Your HIA keeps track of your monthly payment. This payment keeps MyIndyCard active. You will receive a monthly statement in the mail. It shows: How much your payment is When your payment is due Your account number Where to send your payment PLEASE TURN TO THE NEXT PAGE 3

101 CONTINUED FROM PREVIOUS PAGE If you miss a payment, your card won t work for the next month. (See page 14 for more on how this works.) If your income increases, you might start making too much to stay in the Health Care Independence Program. That would mean you need to get health insurance another way. Your HIA can help you. If you make at least six payments in a single year, you can get up to $200 to buy your own health insurance. Go to or call to find out more. 4

102 Using MyIndyCard First, you need to activate your card. Visit to make your card active. You also can call to activate MyIndyCard. When your card is active, you can use it at your doctor s office or pharmacy. You can only use MyIndyCard at doctors and hospitals that are in network. These are the doctors and hospitals your insurance company works with to pay for services at a set price. When you go to an in-network doctor, your co-pays and your share of other costs are lower. If you go to a doctor or hospital not in network, you have to pay your share on your own. It will also be more expensive. PLEASE TURN TO THE NEXT PAGE 5

103 CONTINUED FROM PREVIOUS PAGE Your insurance company will give you a list of doctors and hospitals in its network. You can call your insurance company to find out if a doctor is in network. You can also ask the doctor s office when you make your appointment. Once your card is active, you can start using it. MyIndyCard pays for your part of the cost of visiting the doctor. This is called your co-pay. MyIndyCard takes care of your co-pay at these places, as long as they are in network: Doctors offices Other medical places like hospitals, clinics or physical therapy Pharmacies, but only for prescription drugs The first time you go to the doctor, a worker will ask to see your insurance card. This is the card from your insurance company. You may also be asked to show your driver s license or state ID card. 6

104 And you will be asked for your co-pay. That s when you use MyIndyCard. If your card is working, you won t have to pay anything for your visit that day. If you make your HIA payments on time, you won t have to pay anything for your visit. MyIndyCard also will pay your co-pay for some physical therapy and other tests. If you are not sure, ask your doctor if the office takes MyIndyCard. YourInsurance Member ID: Group Number: Member Name: JOHN K. SMITH MMIS: Office Co-Pay: $25 Specialist Co-Pay: $35 ARKANSAS Effective Date: Prescription Group Number: RX BIN: RX GRP: GROUPP RX PCN: 9999 The Natural State DRIVER S LICENSE NON-DRIVER S ARKANSAS The Natural State ID No: DOB: SMITH JILL K 123 MAIN ST. LITTLE ROCK, AR Issued: Sex: Height: M 6 Endors: Restr: IDENTIFICATION Expires: Eyes: GR ID ONLY 7

105 MyIndyCard Statements Every month, MyIndyCard will mail you a statement that will tell you about your HIA. It will show how much you paid that month and how many co-pays were covered. The statement also will remind you to make your next payment. Your statement will be mailed to you, or you can sign up to get it by . If you would like to get your statement by , visit or call This is the address where you send your monthly payment: You can also pay online at MyIndyCard.org. Service period: This is the month that your payment will cover. If you make your monthly payment, your co-pays will be covered during this time. Participant Name Street Address City, State Zip 3 Re: MyIndyCard Statement 4 THIS IS A BILL Make payment to: MyIndyCard P.O. Box 9664 Conway, AR The MyIndyCard is a new part of your health insurance program and is used to pay your out-of-pocket expenses at Doctors or Pharmacies. Account number: You must pay the amount below to keep your MyIndyCard working. Please include the pay stub This below is with your your HIA monthly payment. You can pay with Check or Money Order. You can also pay online number. at MyIndyCard.org. Include this You must write your Account Number on your check. This is your name and address: Always make sure this information is correct. If you have any questions, go to MyIndyCard.org or call Sign up for e-statements at MyIndyCard.org. Notice for: Account Number: Service Period: Total Amount Due: Date Due: Participant Name /01/ /30/2015 $ /20/ SAMPLE number on the check or money order when you make your payment. 2 Total amount due: This is how much you will pay for that month. Write your check or money order for this amount. Date due: You must make your payment by this date. 8The Statement Below MUST BE DETACHED AND RETURNED with your payment. 9

106 Participant Name Street Address City, State Zip CONTINUED FROM PREVIOUS PAGE Re: MyIndyCard Statement The MyIndyCard is a new part of your health insurance program and is used to pay your out-of-pocket expenses at Doctors or Pharmacies. You must pay the amount below Account to keep number: your MyIndyCard working. This is the month that Please include the pay stub This below is with your your HIA monthly number. payment. You can pay with Check or Money Order. You can also pay online at MyIndyCard.org. You must write your Account Include Number this on number your check. on the Coverage for: This is your name and address. Always make sure this information is correct. If you have any questions, go to MyIndyCard.org or call Sign up for e-statements at MyIndyCard.org. Notice for: Account Number: Service Period: Total Amount Due: Date Due: Participant Name /01/ /30/2015 $ /20/2015 The Statement Below MUST BE DETACHED AND RETURNED with your payment. Coverage For: Account Number: Period: Amount Due: Participant Name /01/ /30/2015 $10.00 Street Address City, State, Zip 4 Amount Due: $10.00 Date Due: 03/20/2015 Write Account Number on check. Make check payable to MyIndyCard. Include this stub with your payment check or money order when you make your payment. This is an example of the payment stub you will send in with your payment. Total Enclosed: Period: your payment will cover. If you make your monthly payment, your co-pays will be covered during this time. SAMPLE 5 6 Amount due: This is how much you will pay for that month. Write your check or money order for this amount. Date due: You must make your payment by this date. Total enclosed: Write the amount that you are paying here

107 Making Payments To keep your card working, you will have to make a monthly payment. Your monthly statement will tell you when to make your payment. You can also find out by logging in to your HIA at or calling How much you pay depends on how much money you make each year and how many people live in your house. You reported this information when you first signed up for the Health Care Independence Program. There are a few ways to make a payment. The easiest way is to pay online at PLEASE TURN TO THE NEXT PAGE 12

108 CONTINUED FROM PREVIOUS PAGE You also can send a check, cashier s check or money order. Mail it to the address on your statement (see page 8). This statement is sent to you each month. Your account number must be on the check or money order. Make sure to include your payment stub from the bottom of your statement. It does not matter who the check is from. Do not send cash. OR 13

109 Penalties If you miss your monthly payment, it will change how you pay at the doctor s office. If you miss a payment, your card will not work the next month. You will have to pay your co-pay on your own at the doctor or pharmacy. You do not have to make up missed payments to make your card work again. Just make your next payment by the 20th of the month. Your card will start working the following month. 14

110 Words to Know Arkansas Health Care Independence Program A state program for health insurance. It helps Arkansans get insurance who can t afford it on their own. Also called the Private Option. Co-pay This is how much you pay for a doctor s visit or medicine. MyIndyCard will pay your co-pay for you. This way, you won t have to pay at the doctor s office. Health Independence Account (HIA) The account for your monthly payment. If you leave the program to get health insurance on your own, your HIA could help you with the new cost. You have to make at least six payments to qualify. More information is on 15

111 Insurance card The card your insurance company gives you. It proves you have insurance with that company. This card has all the information about your insurance plan. Your doctor s office will ask to see this card so they can bill your insurance company. In network The doctors offices, hospitals and pharmacies that have a contract with your insurance company to give you health care at a lower cost. MyIndyCard The card that pays for your co-pay. Make sure you give this card at the doctor s office when they ask for your co-pay. 16

112 Problems with MyIndyCard? If you lose MyIndyCard, call us as soon as possible. This is the best way to stop someone from using your card. The sooner you report the card lost or stolen, the sooner you can get a new card. If you need to change your address, please contact your county DHS office. Other problems? Damaged or destroyed? Need to get a new card? Card not working? Any other questions? Or visit www. MyIndyCard.org

113 For More Information Visit to find out more about MyIndyCard. Watch our short video to learn how the card works. Get more information about the HIA program on the website. If you have questions about your card and you want to speak with a person, call THE ARKANSAS HEALTH CARE INDEPENDENCE PROGRAM IS ADMINISTERED BY THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. REVISED MAR.-2015

114 Medicaid Managed Care Services (MMCS) Information Sheet 1020 W. 4th St., Suite 200 Little Rock, AR Toll free: Transportation Helpline: MMCS PROVIDER RELATIONS Refer to the map and the color key below to find your representative. Manager Amelia Elam Senior Program Coordinator Tonyia Haynes Representatives Becky Andrews Shawna Branscum Kellie Cornelius Carla Hestir Sheryl Hurt Tabitha Kinggard Connie Riley Jerry Wicker BENTON WASHINGTON FRANKLIN CRAWFORD SEBASTIAN POLK LITTLE RIVER SCOTT CARROLL MADISON LOGAN JOHNSON MONTGOMERY PIKE SEVIER HOWARD BOONE CLARK HEMPSTEAD NEVADA MILLER LAFAYETTE YELL NEWTON POPE GARLAND COLUMBIA PERRY HOT SPRING MARION SEARCY BAXTER VAN BUREN CONWAY FAULKNER PULASKI SALINE DALLAS GRANT OUACHITA CALHOUN UNION HP ENTERPRISE SERVICES PROVIDER RELATIONS (Claims Processing) 500 President Clinton Avenue, Suite 400 Little Rock, AR Operator Helpline In state toll free Local / out of state Voice Response System STONE CLEBURNE CLEVELAND BRADLEY FULTON IZARD LONOKE JEFFERSON INDEPENDENCE WHITE LINCOLN DREW ASHLEY SHARP PRAIRIE JACKSON ARKANSAS LAWRENCE WOODRUFF MONROE DESHA CHICOT RANDOLPH CLAY CRAIGHEAD CROSS LEE PHILLIPS GREENE POINSETT ST. FRANCIS CRITTENDEN MISSISSIPPI 4/8/15 Supervisor, Service Relations Jessie Smith , ext. 398 Manager, Provider Relations David Jarnagin STATE OF ARKANSAS ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES ARKIDS FIRST / MEDICAID MEDICAL ASSISTANCE P.O. Box 1437, Slot 1101 Little Rock, AR ARKids First Enrollment Information SPECIAL PROJECTS Central Arkansas Toll free CONNECTCARE Toll free PROVIDER ENROLLMENT HP Enterprise Services, P.O. Box 8105 Little Rock, AR Central Arkansas Fax ARKANSAS MEDICAL SOCIETY REPRESENTATIVE PHYSICIAN OUTREACH SPECIALIST Gloria Boone [email protected]

115 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 ALLERGY-ASTHMA ANTIHYPERLIPIDEMICS ANTIHYPERTENSIVE AGENTS ANTIHISTAMINES -- NASAL & NONSEDATING HMG-CoA REDUCTASE INHIBITORS ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ORIGINAL POSTED PREFERRED STATUS: 1/25/2005 ORIGINAL POSTED PREFERRED STATUS: 3/30/2005 ORIGINAL POSTED PREFERRED STATUS: 11/16/2005 ORIGINAL EDIT EFFECTIVE DATE: 3/25/2005 ORIGINAL EDIT EFFECTIVE DATE: 6/8/2005 ORIGINAL EDIT EFFECTIVE DATE: 11/16/2005 RE-REVIEW POSTED PREFERRED STATUS: 11/2007 RE-REVIEW POSTED PREFERRED STATUS: 4/11/2008 REVISED POSTED PREFERRED STATUS: 11/21/2007 RE-REVIEW POSTED PREFERRED STATUS: 10/26/2010 REVISED EDIT EFFECTIVE DATE: 6/10/2008 REVISED EDIT EFFECTIVE DATE: 1/23/2008 REVISED EDIT EFFECTIVE DATE 12/28/2010 RE-REVIEW POSTED PREFERRED STATUS: 5/27/2014 RE-REVIEW POSTED PREFERRED STATUS: 6/17/2010 REVISED EDIT EFFECTIVE DATE: 5/30/2014 REVISED EDIT EFFECTIVE DATE: 8/17/2010 PREFERRED CETIRIZINE 1MG/ML SOL, 10MG SWALLOW TAB (ZYRTEC) PREFERRED PREFERRED Effective 10/26/2010 ATORVASTATIN (LIPITOR) Effective 5/30/2014 BENAZEPRIL (LOTENSIN) LORATADINE (CLARITIN) PRAVASTATIN (PRAVACHOL) BENAZEPRIL/HCTZ (LOTENSIN HCT) OLOPATADINE NASAL SPRAY (PATANASE) Eff 10/26/2010 SIMVASTATIN (ZOCOR) CAPTOPRIL (CAPOTEN) CAPTOPRIL/HCTZ (CAPOZIDE) NON-PREFERRED -- NON-PREFERRED -- ENALAPRIL (VASOTEC) INCLUDE BUT NOT LIMITED TO INCLUDE BUT NOT LIMITED TO ENALAPRIL/HCTZ (VASERETIC) ACRIVASTINE/PSEUDOEPHEDRINE (SEMPREX-D) ATORVASTATIN (LIPITOR) Effective 5/30/2014 LISINOPRIL (PRINIVIL) AZELASTINE NASAL SPRAY (ASTELIN, ASTEPRO) ATORVASTATIN/EZETIMIBE (LIPTRUZET) LISINOPRIL/HCTZ (PRINZIDE) Effective 12/28/2010 FLUVASTATIN (LESCOL) QUINAPRIL (ACCUPRIL) AZELASTINE/FLUTICASONE NASAL SPRAY (DYMISTA) LOVASTATIN (MEVACOR) QUINAPRIL/HCTZ (ACCURETIC) CETIRIZINE 5MG, 10MG CHEWABLE TAB (ZYRTEC)* LOVASTATIN/NICACIN (ADVICOR) RAMIPRIL CAPSULES (ALTACE CAPSULES) CETIRIZINE/PSEUDOEPHEDRINE (ZYRTEC-D)* PITAVASTATIN (LIVALO) DESLORATADINE (CLARINEX)* Criteria discontinued 12/28/10 ROSUVASTATIN (CRESTOR) NON-PREFERRED -- DESLORATADINE/PSEUDOEPHEDRINE (CLARINEX-D)* SIMVASTATIN/EZETIMIBE (VYTORIN) NON-PREFERRED AGENTS LISTED IN NEXT COLUMN FEXOFENADINE (ALLEGRA)* SIMVASTATIN/NIACIN (SIMCOR) FEXOFENADINE/PSEUDOEPHEDRINE (ALLEGRA-D)* SIMVASTATIN/SITAGLIPTIN (JUVISYNC) LEVOCETIRIZINE (XYZAL)* LORATADINE/PSEUDOEPHEDRINE (CLARITIN-D)* *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 1 of 14

116 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 ANTIHYPERTENSIVE AGENTS ANTIHYPERTENSIVE AGENTS ANTIHYPERTENSIVE AGENTS ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ANGIOTENSIN II RECEPTOR ANTAGONISTS ANGIOTENSIN II RECEPTOR ANTAGONISTS ORIGINAL POSTED PREFERRED STATUS: 11/16/2005 ORIGINAL POSTED PREFERRED STATUS: 12/20/2005 ORIGINAL POSTED PREFERRED STATUS: 12/20/2005 ORIGINAL EDIT EFFECTIVE DATE: 11/16/2005 ORIGINAL EDIT EFFECTIVE DATE: 2/21/2006 ORIGINAL EDIT EFFECTIVE DATE: 2/21/2006 REVISED POSTED PREFERRED STATUS: 11/21/2007 REVISED POSTED PREFERRED STATUS: 8/12/2011 REVISED POSTED PREFERRED STATUS: 8/12/2011 REVISED EDIT EFFECTIVE DATE: 1/23/2008 REVISED EDIT EFFECTIVE DATE: 10/12/2011 REVISED EDIT EFFECTIVE DATE: 10/12/2011 RE-REVIEW POSTED PREFERRED STATUS: 6/17/2010 RE-REVIEW POSTED PREFERRED STATUS: 3/6/2013 RE-REVIEW POSTED PREFERRED STATUS: 3/6/2013 REVISED EDIT EFFECTIVE DATE: 8/17/2010 REVISED EDIT EFFECTIVE DATE: 5/7/2013 REVISED EDIT EFFECTIVE DATE: 5/7/2013 * New Clinical Criteria Effective 8/17/2010 * New Clinical Criteria Effective 8/17/2010 NON-PREFERRED -- INCLUDE BUT NOT LIMITED TO PREFERRED NON-PREFERRED -- BENAZEPRIL/AMLODIPINE (LOTREL) DIOVAN* (Brand only) Effective 5/7/2013 INCLUDE BUT NOT LIMITED TO ENALAPRIL SUSPENSION (EPANED) IRBESARTAN (AVAPRO)* Effective 5/7/2013 AZILSARTAN (EDARBI) FOSINOPRIL (MONOPRIL) IRBESARTAN/HCTZ (AVALIDE)* Effective 5/7/2013 AZILSARTAN/CHLORTHALIDONE (EDARBYCLOR) FOSINOPRIL/HCTZ (MONOPRIL HCT) LOSARTAN (COZAAR)* CANDESARTAN (ATACAND)* MOEXIPRIL (UNIVASC) LOSARTAN/HCTZ (HYZAAR)* CANDESARTAN/HCTZ (ATACAND HCT) MOEXIPRIL/HCTZ (UNIRETIC) OLMESARTAN (BENICAR)* EPROSARTAN (TEVETEN) PERINDOPRIL (ACEON) OLMESARTAN/AMLODIPINE (AZOR)* EPROSARTAN/HCTZ (TEVETEN HCT) RAMIPRIL TABLETS (ALTACE TABLETS) OLMESARTAN/HCTZ (BENICAR HCT)* IRBESARTAN (AVAPRO) Effective 5/7/2013 TRANDOLAPRIL (MAVIK) OLMESARTAN/AMLODIPINE/HCTZ (TRIBENZOR)* Eff 10/12/11 IRBESARTAN/HCTZ (AVALIDE) Effective 5/7/2013 TRANDOLAPRIL/VERAPAMIL (TARKA) VALSARTAN (DIOVAN Generic)* Effective 5/7/2013 OLMESARTAN/AMLODIPINE/HCTZ (TRIBENZOR) Eff 10/12/11 VALSARTAN/ALISKIREN (VALTURNA)* TELMISARTAN (MICARDIS) VALSARTAN/AMLODIPINE (EXFORGE)* TELMISARTAN/AMLODIPINE (TWYNSTA) VALSARTAN/AMLODIPINE/HCTZ (EXFORGE HCT)* TELMISARTAN/HCTZ (MICARDIS HCT) VALSARTAN/HCTZ (DIOVAN HCT)* Effective 3/15/2014 VALSARTAN (DIOVAN - Generic only) Effective 5/7/2013 *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 2 of 14

117 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 ANTIHYPERTENSIVE AGENTS ANTIHYPERTENSIVE AGENTS ANTIHYPERTENSIVE AGENTS BETA ADRENERGIC BLOCKERS CALCIUM CHANNEL BLOCKERS DIRECT RENIN INHIBITORS ORIGINAL POSTED PREFERRED STATUS: 7/18/2005 ORIGINAL POSTED PREFERRED STATUS: 5/12/2005 ORIGINAL POSTED PREFERRED STATUS: 6/17/2010 ORIGINAL EDIT EFFECTIVE DATE: 10/5/2005 ORIGINAL EDIT EFFECTIVE DATE: 7/12/2005 ORIGINAL EDIT EFFECTIVE DATE: 8/17/2010 RE-REVIEW POSTED PREFERRED STATUS: 10/17/2007 RE-REVIEW POSTED PREFERRED STATUS: 6/17/2010 REVISED EDIT EFFECTIVE DATE: 8/17/2010 PREFERRED PREFERRED ALISKIREN (TEKTURNA)* Effective 8/17/2010 ATENOLOL (TENORMIN) PREFERRED ALISKIREN/HCTZ (TEKTURNA HCT)* Effective 8/17/2010 METOPROLOL TARTRATE (LOPRESSOR) AMLODIPINE (NORVASC) ALISKIREN/VALSARTAN (VALTURNA)* Effective 8/17/2010 PROPRANOLOL IMMEDIATE RELEASE (INDERAL) AMLODIPINE/OLMESARTAN (AZOR)* AMLODIPINE/OLMESARTAN/HCTZ (TRIBENZOR)* Eff 10/12/11 NON-PREFERRED -- PREFERRED FOR CHF ONLY AMLODIPINE/VALSARTAN (EXFORGE)* INCLUDE BUT NOT LIMITED TO BISOPROLOL FUMARATE (ZEBETA)* AMLODIPINE/VALSARTAN/HCTZ (EXFORGE HCT)* ALISKIREN/AMLODIPINE (AMTURNIDE) CARVEDILOL TABLET (COREG)* DILTIAZEM ER 120MG, 180MG, 240MG CAPSULE ALISKIREN/AMLODIPINE (TEKAMLO) METOLOPROL SUCCINATE ER (TOPROL XL)* (DILACOR XR) NIFEDIPINE CC, ER (ADALAT CC, PROCARDIA XL) NON-PREFERRED -- VERAPAMIL SR TABLETS 120MG, 180MG, AND 240MG INCLUDE BUT NOT LIMITED TO (CALAN SR) ACEBUTOLOL (SECTRAL) BETAXOLOL HCL (KERLONE) NON-PREFERRED -- CARVEDILOL PHOSPHATE (COREG CR) INCLUDE BUT NOT LIMITED TO LABETALOL HCL (NORMODYNE) AMLODIPINE/ATORVASTATIN (CADUET) NADOLOL (CORGARD) AMLODIPINE/OLMESARTAN/HCTZ (TRIBENZOR) Eff 10/12/11 NEBIVOLOL (BYSTOLIC) DILTIAZEM CD, ER, LA, SA, XR, OR XT (CARDIZEM, TIAZAC) PENBUTOLOL (LEVATOL) FELODIPINE ER (PLENDIL) PINDOLOL (VISKEN) ISRADIPINE (DYNACIRC) PROPRANOLOL EXTENDED RELEASE (INDERAL LA) ISRADIPINE CR (DYNACIRC CR) PROPRANOLOL SOLUTION (HEMANGEOL) NICARDIPINE (CARDENE) TIMOLOL MALEATE (BLOCADREN) NICARDIPINE ER (CARDENE SR) NISOLDIPINE ER (SULAR ER) VERAPAMIL SR CAPSULES (VERELAN) *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 3 of 14

118 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 BIOLOGIC AND IMMUNOLOGIC AGENTS BIOLOGIC AND IMMUNOLOGIC AGENTS CENTRAL NERVOUS SYSTEM AGENTS IMMUNOLOGIC AGENTS IMMUNOLOGIC AGENTS ANTIDEPRESSANTS Disease-modifying Drugs for Multiple Sclerosis Targeted Immune Modulators SSRIs, SSNRIs, SNRIs ORIGINAL POSTED PREFERRED STATUS: 7/28/2011 ORIGINAL POSTED PREFERRED STATUS: 4/14/2006 ORIGINAL POSTED PREFERRED STATUS: 2/7/2007 ORIGINAL EDIT EFFECTIVE DATE: 9/27/2011 ORIGINAL EDIT EFFECTIVE DATE: 6/13/2006 ORIGINAL EDIT EFFECTIVE DATE: 4/10/2007 ORIGINAL POSTED PREFERRED STATUS: 5/6/2014 RE-REVIEW POSTED PREFERRED STATUS: 8/22/2007 RE-REVIEW POSTED PREFERRED STATUS: 10/8/2009 ORIGINAL EDIT EFFECTIVE DATE: 7/8/2014 REVISED EDIT EFFECTIVE DATE: 10/17/2007 REVISED EDIT EFFECTIVE DATE: 1/1/2010 RE-REVIEW POSTED PREFERRED STATUS: 5/31/2012 RE-REVIEW POSTED PREFERRED STATUS: 5/2/2011 PREFERRED REVISED EDIT EFFECTIVE DATE: 7/1/2012 REVISED EDIT EFFECTIVE DATE: 7/1/2011 GLATIRAMER 20MG (COPAXONE) RE-REVIEW POSTED PREFERRED STATUS: 5/6/2014 GLATIRAMER 40MG (COPAXONE) Effective 7/8/2014 PREFERRED REVISED EDIT EFFECTIVE DATE: 6/5/2014 INTERFERON BETA - 1A (AVONEX) ADALIMUMAB (HUMIRA)* INTERFERON BETA - 1B (BETASERON) Effectivve 7/8/2014 CERTOLIZUMAB (CIMZIA)* Effective 7/1/2012 ETANERCEPT (ENBREL)* PREFERRED NON-PREFERRED -- BUPROPION EXTENDED RELEASE (WELLBUTRIN XL)* INCLUDE BUT NOT LIMITED TO NON-PREFERRED -- BUPROPION REGULAR RELEASE (WELLBUTRIN)* DIMETHYL FUMARATE (TECFIDERA) INCLUDE BUT NOT LIMITED TO BUPROPION SUSTAINED RELEASE (WELLBUTRIN SR)* GLATIRAMER 40MG (COPAXONE) Effective 7/8/2014 ABATACEPT (ORENCIA) CITALOPRAM (CELEXA)* FINGOLIMOD (GILENYA) ANAKINRA (KINERET) ESCITALOPRAM 5MG TABLET, 5MG/5ML SOL'N (LEXAPRO)* INTERFERON BETA - 1A/ALBUMIN (REBIF) APREMILAST (OTEZLA) ESCITALOPRAM 10MG, 20MG TABLET (LEXAPRO)* INTERFERON BETA - 1B (BETASERON) Effective 7/8/2014 CERTOLIZUMAB (CIMZIA) Effective 7/1/2012 FLUOXETINE 10MG, 20MG CAPSULE, AND 20MG/5ML INTERFERON BETA - 1B KIT (EXTAVIA) GOLIMUMAB (SIMPONI) SOLUTION (PROZAC)* PEGINTERFERON BETA - 1A (PLEGRIDY) INFLIXIMAB (REMICADE) FLUVOXAMINE (LUVOX)* TERIFLUNOMIDE (AUBAGIO) TOCILIZUMAB (ACTEMRA) MIRTAZAPINE 7.5MG (REMERON)* Effective 6/5/2014 TOFACITINIB (XELJANZ) MIRTAZAPINE 15MG, 30MG, 45MG TABLET (REMERON)* USTEKINUMAB (STELARA) PAROXETINE HCL TABLET (PAXIL)* SERTRALINE (ZOLOFT)* VENLAFAXINE ER CAPSULES (EFFEXOR XR)* Effective 6/5/14 VENLAFAXINE REGULAR RELEASE TABLET (EFFEXOR)* NON-PREFERRED -- NON-PREFERRED AGENTS LISTED IN NEXT COLUMN *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 4 of 14

119 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS ANTIDEPRESSANTS ANTIEMETICS ATTENTION DEFICIT DISORDER/HYPERACTIVITY DISORDER SSRIs, SSNRIs, SNRIs 5-HT3 & NK1 Receptor Antagonists Amphetamine Salts, Amphetamine-Like Drugs, and Norepinephrine Reuptake Inhibitors ORIGINAL POSTED PREFERRED STATUS: 2/7/2007 ORIGINAL POSTED PREFERRED STATUS: 8/10/2006 ORIGINAL EDIT EFFECTIVE DATE: 4/10/2007 ORIGINAL EDIT EFFECTIVE DATE: 10/10/2006 ORIGINAL POSTED PREFERRED STATUS: 5/7/2007 RE-REVIEW POSTED PREFERRED STATUS: 10/8/2009 RE-REVIEW POSTED PREFERRED STATUS: 7/14/2009 ORIGINAL EDIT EFFECTIVE DATE: 7/10/2007 REVISED EDIT EFFECTIVE DATE: 1/1/2010 REVISED EDIT EFFECTIVE DATE: 9/14/2009 REVISED POSTED PREFERRED STATUS: 5/11/2009 RE-REVIEW POSTED PREFERRED STATUS: 5/2/2011 REVISED EDIT EFFECTIVE DATE: 7/21/2009 REVISED EDIT EFFECTIVE DATE: 7/1/2011 PREFERRED RE-REVIEW POSTED PREFERRED STATUS: 2/16/2012 RE-REVIEW POSTED PREFERRED STATUS: 5/6/2014 ONDANSETRON 4MG, 8MG ORAL DISINTEGRATING REVISED EDIT EFFECTIVE DATE: 4/17/2012 REVISED EDIT EFFECTIVE DATE: 6/5/2014 TABLET (ZOFRAN)* RE-REVIEW POSTED PREFERRED STATUS: 12/5/2014 ONDANSETRON 4MG, 8MG TABLET (ZOFRAN)* REVISED EDIT EFFECTIVE DATE: 2/3/2015 ONDANSETRON 4MG/2ML PRESERVATIVE FREE VIAL* NON-PREFERRED -- ONDANSETRON 40MG/20ML VIAL (ZOFRAN)* PREFERRED INCLUDE BUT NOT LIMITED TO ADDERALL XR* (Brand only) Effective 4/17/2012 BUPROPION HBR ER TABLET (APLENZIN)* NON-PREFERRED -- AMPHETAMINE SALTS TABLET (ADDERALL)* BUPROPION HCL ER TABLET (FORFIVO XL)* INCLUDE BUT NOT LIMITED TO ATOMOXETINE (STRATTERA)* Effective 2/3/2015 DESVENLAFAXINE ER (KHEDEZLA ER, PRISTIQ ER)* APREPITANT (EMEND) DEXTROAMPHETAMINE 5MG, 10MG TABLET* DULOXETINE (CYMBALTA)* DOLASETRON (ANZEMET) FOCALIN* (Brand only) Effective 4/17/2012 FLUOXETINE 10MG, 15MG, 20MG TABLET, 40MG CAPSULE, GRANISETRON (KYTRIL, SANCUSO) FOCALIN XR* (Brand only) AND 90MG DELAYED RELEASE (PROZAC)* NETUPITANT/PALONOSETRON (AKYNZEO) LISDEXAMFETAMINE (VYVANSE)* FLUVOXAMINE EXTENDED RELEASE (LUVOX CR) ONDANSETRON 24MG TABLET (ZOFRAN) METHLYPHENIDATE ER PATCH (DAYTRANA)* Effective 2/3/15 LEVOMILNACIPRAN (FETZIMA ER)* ONDANSETRON 32MG/50ML BAG (ZOFRAN) METHYLPHENIDATE SWALLOW TABLET (RITALIN)* MILNACIPRAN (SAVELLA)* ONDANSETRON 4MG/2ML AMPULE/SYRINGE (ZOFRAN) MIRTAZAPINE 7.5MG (REMERON)* Effective 6/5/2014 ONDANSETRON 4MG/5ML SOLUTION (ZOFRAN) NON-PREFERRED -- MIRTAZAPINE ODT TABLET (REMERON SOLTAB)* ONDANSETRON SOLUBLE FILM (ZUPLENZ) NON-PREFERRED AGENTS LISTED IN NEXT COLUMN NEFAZODONE (SERZONE)* PAROXETINE CR TABLET; SUSPENSION (PAXIL)* PAROXETINE MESYLATE (BRISDELLE) PAROXETINE MESYLATE (PEXEVA)* VENLAFAXINE ER CAPSULES (EFFEXOR XR)* Effective 6/5/14 VILAZODONE (VIIBRYD)* VORTIOXETINE (BRINTELLIX)* *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 5 of 14

120 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT DISORDER/HYPERACTIVITY DISORDER FIBROMYALGIA AGENTS FIBROMYALGIA AGENTS Amphetamine Salts, Amphetamine-Like Drugs, and Norepinephrine Reuptake Inhibitors ORIGINAL POSTED PREFERRED STATUS 7/20/2011 ORIGINAL POSTED PREFERRED STATUS 7/20/2011 ORIGINAL EDIT EFFECTIVE DATE: 9/20/2011 ORIGINAL EDIT EFFECTIVE DATE: 9/20/2011 SEE ORIGINAL AND PREVIOUS POSTING DATES IN PREFERRED ADD/ADHD COLUMN PREFERRED NON-PREFERRED -- CONTINUED FROM PREVIOUS COLUMN RE-REVIEW POSTED PREFERRED STATUS: 12/5/2014 AMITRIPTYLINE (ELAVIL) INCLUDE BUT NOT LIMITED TO REVISED EDIT EFFECTIVE DATE: 2/3/2015 CITALOPRAM (CELEXA)* CYCLOBENAZAPRINE 10MG TABLET (FLEXERIL) FLUOXETINE 10MG, 15MG, 20MG TABLET, 40MG CAPSULE & NON-PREFERRED -- FLUOXETINE 10MG, 20MG CAPSULE, 20MG/5ML SOLUTION 90MG DELAYED RELEASE (PROZAC, SARAFEM)* INCLUDE BUT NOT LIMITED TO (PROZAC)* FLUVOXAMINE EXTENDED RELEASE CAPSULE (LUVOX CR)* AMPHETAMINE SALTS ER CAPSULE (ADDERALL XR - Generic GABAPENTIN CAPSULE (NEURONTIN) FLUVOXAMINE TABLET (LUVOX)* only) NORTRIPTYLINE (PAMELOR) GABAPENTIN 250MG/5ML SOLUTION (NEURONTIN)* ATOMOXETINE (STRATTERA)* Effective 2/3/2015 PAROXETINE HCL TABLET (PAXIL)* GABAPENTIN 600MG, 800MG TABLET (NEURONTIN)* DEXMETHYLPHENIDATE ER CAPSULE (FOCALIN XR - Generic IMIPRAMINE (TOFRANIL)* only) NON-PREFERRED -- LACOSAMIDE (VIMPAT)* DEXMETHYLPHENIDATE TABLET (FOCALIN - Generic only) INCLUDE BUT NOT LIMITED TO LAMOTRIGINE (LAMICTAL)* CLONIDINE ER SUSPENSION (NEXICLON XR) BUPROPION HBR ER TABLET (APLENZIN)* LEVETIRACETAM (KEPPRA)* CLONIDINE ER TABLET (KAPVAY ER, NEXICLON XR) BUPROPION EXTENDED RELEASE (WELLBUTRIN XL)* MILNACIPRAN (SAVELLA)* DEXTROAMPHETAMINE CAPSULE (DEXEDRINE SPANSULE) BUPROPION REGULAR RELEASE (WELLBUTRIN)* MIRTAZAPINE (REMERON)* DEXTROAMPHETAMINE SOLUTION (PROCENTRA) BUPROPION SUSTAINED RELEASE (WELLBUTRIN SR)* NEFAZODONE (SERZONE)* DEXTROAMPHETAMINE 2.5MG, 7.5MG, 15MG, 20MG, 30MG CARBAMAZEPINE CHEWABLE TABLET (TEGRETOL CHEW TAB)*OXCARBAZEPINE (TRILEPTAL)* TABLET (ZENZEDI) CARBAMAZEPINE EXTENDED RELEASE CAPSULE PAROXETINE EXTENDED RELEASE & SUSPENSION (PAXIL)* GUANFACINE ER TABLET (INTUNIV ER) (CARBATROL ER, EQUETRO)* PAROXETINE MESYLATE (PEXEVA)* METHAMPHETAMINE TABLET (DESOXYN) CARBAMAZEPINE IMMEDIATE RELEASE TABLET (TEGRETOL)* PHENYTOIN 100MG ER CAPSULE (DILANTIN)* METHYLPHENIDATE CHEWABLE TABLET (METHYLIN) CARBAMAZEPINE SUSPENSION (TEGRETOL)* PREGABALIN (LYRICA)* METHYLPHENIDATE ER CAPSULE (METADATE CD, RITALIN LA) CYCLOBENZAPRINE 5MG, 7.5MG TABLET (FEXMID, FLEXERIL) SERTRALINE (ZOLOFT)* METHLYPHENIDATE ER PATCH (DAYTRANA)* Effective 2/3/15 CYCLOBENZAPRINE ER CAPSULE (AMRIX) TIAGABINE (GABITRIL)* METHYLPHENIDATE ER SUSPENSION (QUILLIVANT XR) DESIPRAMINE (NORPRAMIN)* TOPIRAMATE (TOPAMAX)* METHYLPHENIDATE ER TABLET (CONCERTA)* Eff 4/17/2012 DESVENLAFAXINE (PRISTIQ)* VALPROIC ACID (DEPAKENE, STAVZOR)* METHYLPHENIDATE ER TABLET (METADATE ER,RITALIN SR) DIVALPROEX SODIUM (DEPAKOTE)* VENLAFAXINE EXTENDED RELEASE CAPSULES (EFFEXOR XR) METHYLPHENIDATE SOLUTION (METHYLIN) DULOXETINE (CYMBALTA)* VENLAFAXINE EXTENDED RELEASE TABLET* ESCITALOPRAM (LEXAPRO)* VENLAFAXINE TABLET (EFFEXOR)* ETHOTOIN TABLET (PEGANONE)* ZONISAMIDE (ZONEGRAN)* NON-PREFERRED AGENTS CONTINUED IN NEXT COLUMN ***SEE DISCLAIMER ON LAST PAGE*** *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 6 of 14

121 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS MIGRAINE AGENTS NARCOTIC AGONIST ANALGESICS NEUROPATHIC PAIN AGENTS Serotonin 5-HT1 Receptor Agonist LONG-ACTING OPIOIDS ORIGINAL POSTED PREFERRED STATUS: 4/3/2008 ORIGINAL POSTED PREFERRED STATUS: 12/8/2005 ORIGINAL POSTED PREFERRED STATUS: 8/26/2005 ORIGINAL EDIT EFFECTIVE DATE: 6/5/2008 ORIGINAL EDIT EFFECTIVE DATE: 2/7/2006 ORIGINAL EDIT EFFECTIVE DATE: 10/26/2005 RE-REVIEW POSTED PRERERRED STATUS: 10/14/2011 REVISED POSTED PREFERRED STATUS: 7/25/2007 REVISED POSTED PREFERRED STATUS: 8/4/2008 REVISED EDIT EFFECTIVE DATE: 12/13/2011 REVISED EDIT EFFECTIVE DATE: 10/1/2007 REVISED EDIT EFFECTIVE DATE: 8/1/2008 RE-REVIEW POSTED PREFERRED STATUS: 4/26/2010 RE-REVIEW POSTED PREFERRED STATUS: 10/14/2011 PREFERRED REVISED EDIT EFFECTIVE DATE: 7/1/2010 REVISED EDIT EFFECTIVE DATE: 1/10/2012 AMITRIPTYLINE (ELAVIL) CARBAMAZEPINE CHEWABLE TABLET (TEGRETOL CHEW TAB PREFERRED PREFERRED CARBAMAZEPINE IMMEDIATE RELEASE TABLET (TEGRETOL) RIZATRIPTAN (MAXALT)* Effective 7/1/2010 METHADONE (DOLOPHINE)* GABAPENTIN CAPSULE (NEURONTIN) RIZATRIPTAN DISINTEGRATING (MAXALT MLT)* Eff 7/1/2010 MORPHINE SULFATE LA TABLET (MS CONTIN, ORAMORPH)* GABAPENTIN 600MG, 800MG TAB (NEURONTIN) Eff 12/13/11 SUMATRIPTAN 4MG/0.5ML KIT REFILL (IMITREX)* OXYMORPHONE ER TABLET (OPANA ER)* Effective 1/10/2012 NORTRIPTYLINE (PAMELOR) SUMATRIPTAN 5MG NASAL SPRAY (IMITREX)* PREGABALIN (LYRICA)* Effective 12/13/2011 SUMATRIPTAN 6MG/0.5ML KIT REFILL (IMITREX)* NON-PREFERRED -- VENLAFAXINE REGULAR RELEASE TABLET (EFFEXOR)* SUMATRIPTAN 6MG/0.5ML KIT SYRINGE (IMITREX)* INCLUDE BUT NOT LIMITED TO SUMATRIPTAN 6MG/0.5ML VIAL (IMITREX)* BUPRENORPHINE PATCH (BUTRANS) NON-PREFERRED -- SUMATRIPTAN 20MG NASAL SPRAY (IMITREX)* FENTANYL PATCH (DURAGESIC)* INCLUDE BUT NOT LIMITED TO SUMATRIPTAN TABLET (IMITREX)* HYDROMORPHONE ER TABLET (EXALGO ER)* CARBAMAZEPINE EXTENDED RELEASE CAPSULE & TABLET SUMATRIPTAN/NAPROXEN (TREXIMET)* Effective 7/1/2010 MORPHINE SULFATE ER CAPSULE (AVINZA, KADIAN)* (CARBATROL ER, EQUETRO, TEGRETOL XR)* MORPHINE/NALTREXONE (EMBEDA)* CARBAMAZEPINE SUSPENSION (TEGRETOL)* NON-PREFERRED -- OXYCODONE-ACETAMINOPHEN ER TABLET (XARTEMIX XR)* DIVALPROEX SODIUM (DEPAKOTE)* INCLUDE BUT NOT LIMITED TO OXYCODONE ER TABLET (OXYCONTIN)* DULOXETINE (CYMBALTA)* AMLOTRIPTAN (AXERT) OXYMORPHONE ER TABLET (OPANA ER)* Effective 1/10/2012 GABAPENTIN 250MG/5ML SOLUTION (NEURONTIN)* ELETRIPTAN (RELPAX) TAPENTADOL ER TABLET (NUCYNTA ER)* GABAPENTIN TABLET (NEURONTIN)* Effective 12/13/2011 FROVATRIPTAN (FROVA) GABAPENTIN EXTENDED RELEASE CAPSULE (GRALISE) NARATRIPTAN (AMERGE) GABAPENTIN EXTENDED RELEASE TABLET (HORIZANT) RIZATRIPTAN (MAXALT) Effective 7/1/2010 LACOSAMIDE (VIMPAT)* RIZATRIPTAN DISINTEGRATING (MAXALT MLT)* Eff 7/1/2010 LAMOTRIGINE (LAMICTAL)* SUMATRIPTAN 4MG/0.5ML VIAL (IMITREX) SUMATRIPTAN 4MG/0.5ML INJECTION (SUMAVEL DOSEPRO) NON-PREFERRED AGENTS CONTINUED IN NEXT COLUMN SUMATRIPTAN 6MG/0.5ML INJECTION (SUMAVEL DOSEPRO) SUMATRIPTAN/NAPROXEN (TREXIMET) Effective 7/1/2010 ZOLMITRIPTAN (ZOMIG) ***SEE DISCLAIMER ON LAST PAGE*** *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 7 of 14

122 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS NEUROPATHIC PAIN AGENTS NON-BENZODIAZEPINE SEDATIVE HYNOTICS NONSTEROIDAL ANTIINFLAMMATORY AGENTS ORIGINAL POSTED PREFERRED STATUS: 4/3/2008 ORIGINAL POSTED PREFERRED STATUS: 3/7/2006 ORIGINAL EDIT EFFECTIVE DATE: 6/5/2008 ORIGINAL EDIT EFFECTIVE DATE: 5/9/2006 ORIGINAL POSTED PREFERRED STATUS: 4/13/2007 RE-REVIEW POSTED PRERERRED STATUS: 10/14/2011 REVISED POSTED PREFERRED STATUS: 12/15/2008 ORIGINAL EDIT EFFECTIVE DATE: 6/18/2007 REVISED EDIT EFFECTIVE DATE: 12/13/2011 REVISED EDIT EFFECTIVE DATE: 3/1/2009 RE-REVIEW POSTED PREFERRED STATUS: 4/07/2011 RE-REVIEW POSTED PREFERRED STATUS: 11/28/2011 REVISED EDIT EFFECTIVE DATE: 6/7/2011 NON-PREFERRED -- CONTINUED FROM PREVIOUS COLUMN REVISED EDIT EFFECTIVE DATE: 2/28/2012 INCLUDE BUT NOT LIMITED TO PREFERRED PREFERRED DICLOFENAC SODIUM ER 100MG TABLET LIDOCAINE PATCH (LIDODERM)* ZALEPLON (SONATA)* (VOLTAREN XR 100MG) Effective 6/7/2011 OXCARBAZEPINE (TRILEPTAL)* ZOLPIDEM TABLET (AMBIEN)* IBUPROFEN 100MG/5ML SUSPENSION, 400MG, 600MG, PREGABALIN (LYRICA)* Effective 12/13/ MG TABLET (MOTRIN) TOPIRAMATE (TOPAMAX)* NON-PREFERRED -- INDOMETHACIN 25MG, 50MG CAPSULE (INDOCIN) Eff 6/7/2011 VALPROIC ACID (DEPAKENE, STAVZOR)* INCLUDE BUT NOT LIMITED TO KETOPROFEN 50MG, 75MG CAPSULE (ORUDIS) VENLAFAXINE ER CAPSULE (EFFEXOR XR)* DOXEPIN (SILENOR) KETOROLAC TABLET (TORADOL)* ESZOPICLONE (LUNESTA) MELOXICAM 7.5MG, 15MG TABLET (MOBIC) RAMELTEON (ROZEREM) Effective 2/28/2012 NAPROXEN 250MG, 375MG, 500MG TABLET (NAPROSYN) SUVOREXANT (BELSOMRA) NAPROXEN 375MG, 500MG EC TABLET (EC-NAPROSYN) ZOLPIDEM CR TABLET (AMBIEN CR) NAPROXEN SODIUM 275MG, 550MG TABLET (ANAPROX) ZOLPIDEM ORAL SPRAY (ZOLPIMIST) SALSALATE 750MG (SALFLEX-750) ZOLPIDEM SL TABLET (EDLUAR, INTERMEZZO) NON-PREFERRED -- INCLUDE BUT NOT LIMITED TO CELECOXIB (CELEBREX) DICLOFENAC EPOLAMINE (FLECTOR) DICLOFENAC POTASSIUM (CAMBIA, CATAFLAM, ZIPSOR) DICLOFENAC SODIUM (TOPICAL GEL & SOLUTION; 25MG, 50MG, 75MG TABLET) Eff 6/7/2011 DICLOFENAC SODIUM/MISOPROSTOL (ARTHROTEC) DICLOFENAC SUBMICRONIZED (ZORVOLEX) DIFLUNISAL (DOLOBID) ***SEE DISCLAIMER ON LAST PAGE*** NON-PREFERRED AGENTS CONTINUED IN NEXT COLUMN *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 8 of 14

123 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS ENDOCRINE AND METABOLIC AGENTS NONSTEROIDAL SKELETAL MUSCLE RELAXANTS ANTIDIABETIC AGENTS ANTIINFLAMMATORY AGENTS Meglitinides ORIGINAL POSTED PREFERRED STATUS: 1/18/2006 ORIGINAL POSTED PREFERRED STATUS: 4/13/2007 ORIGINAL EDIT EFFECTIVE DATE: 3/20/2006 ORIGINAL POSTED PREFERRED STATUS: 9/29/2006 ORIGINAL EDIT EFFECTIVE DATE: 6/18/2007 ORIGINAL EDIT EFFECTIVE DATE: 11/28/2006 RE-REVIEW POSTED PREFERRED STATUS: 4/07/2011 PREFERRED REVISED POSTED PREFERRED STATUS: 11/12/2008 REVISED EDIT EFFECTIVE DATE: 6/7/2011 BACLOFEN TABLETS (LIORESAL)* REVISED EDIT EFFECTIVE DATE: 1/1/2009 CHLORZOXAZONE 500MG (PARAFON) RE-REVIEW POSTED PREFERRED STATUS: 9/7/2011 NON-PREFERRED -- CONTINUED FROM PREVIOUS COLUMN CYCLOBENZAPRINE 10MG TABLET (FLEXERIL) REVISED EDIT EFFECTIVE DATE: 1/1/2012 INCLUDE BUT NOT LIMITED TO METHOCARBAMOL (ROBAXIN) ETODOLAC (LODINE) TIZANIDINE TABLET (ZANAFLEX)* PREFERRED FENOPROFEN (NALFON) NATEGLINIDE (STARLIX) FLURBIPROFEN (ANSAID) NON-PREFERRED -- IBUPROFEN 40MG/ML SUSPENSION; 50MG, 100MG TABLET INCLUDE BUT NOT LIMITED TO NON-PREFERRED -- (MOTRIN) CARISOPRODOL (SOMA) INCLUDE BUT NOT LIMITED TO IBUPROFEN/CAFF/B1/B2/B6/B12 (IC400, IC800 KIT) CARISOPRODOL/ASA (SOMA COMPOUND) REPAGLINIDE (PRANDIN) Effective 1/1/2012 IBUPROFEN/FAMOTIDINE (DUEXIS) CARISOPRODOL/ASA/CODEINE (SOMA COMPOUND W/ COD) REPAGLINIDE/METFORMIN (PRANDIMET) INDOMETHACIN 75MG SA CAPSULE; 50MG SUPPOSITORY CHLORZOXAZONE 375MG, 750MG (LORZONE) 25MG/5ML SUSPENSION (INDOCIN) CYCLOBENZAPRINE 5MG, 7.5MG TABLET (FLEXERIL, FEXMID) KETOPROFEN 200MG CAPSULE SA (ORUVAIL) CYCLOBENZAPRINE ER CAPSULE (AMRIX) KETOROLAC NASAL SPRAY (SPRIX) DANTROLENE (DANTRIUM) MECLOFENAMATE (MECLOMEN) METAXOLONE (SKELAXIN) MEFENAMIC ACID (PONSTEL) ORPHENADRINE CITRATE (NORFLEX) MELOXICAM SUSPENSION (MOBIC) ORPHENADRINE/ASPIRIN/CAFFEINE (NORGESIC) NABUMETONE (RELAFEN) TIZANIDINE CAPSULES (ZANAFLEX) NAPROXEN/ESOMEPRAZOLE (VIMOVO) NAPROXEN SUSPENSION (NAPROSYN) NAPROXEN NA 375MG, 500MG TABLET (NAPRELAN) OXAPROZIN (DAYPRO) PIROXICAM (FELDENE) Effective 6/7/2011 SALSALATE 500MG (SALFLEX-500) Effective 6/7/2011 SULINDAC (CLINORIL) TOLMETIN (TOLECTIN) *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 9 of 14

124 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ANTIDIABETIC AGENTS ANTIDIABETIC AGENTS ANTIDIABETIC AGENTS Newer Agents Sulfonlyurea Thiazoladinediones ORIGINAL POSTED PREFERRED STATUS: 11/12/2008 ORIGINAL POSTED PREFERRED STATUS: 9/29/2006 ORIGINAL POSTED PREFERRED STATUS: 9/29/2006 ORIGINAL EDIT EFFECTIVE DATE: 1/1/2009 ORIGINAL EDIT EFFECTIVE DATE: 11/28/2006 ORIGINAL EDIT EFFECTIVE DATE: 11/28/2006 REVISED POSTED PREFERRED STATUS: 11/12/2008 REVISED POSTED PREFERRED STATUS: 11/12/2008 NON-PREFERRED -- REVISED EDIT EFFECTIVE DATE: 1/1/2009 REVISED EDIT EFFECTIVE DATE: 1/1/2009 INCLUDE BUT NOT LIMITED TO RE-REVIEW POSTED PREFERRED STATUS: 9/7/2011 RE-REVIEW POSTED PREFERRED STATUS: 9/7/2011 ALBIGLUTIDE (TANZEUM) REVISED EDIT EFFECTIVE DATE: 1/1/2012 REVISED EDIT EFFECTIVE DATE: 1/1/2012 ALOGLIPTIN (NESINA) ALOGLIPTIN/METFORMIN (KAZANO) PREFERRED PREFERRED ALOGLIPTIN/PIOGLITAZONE (OSENI) CHLORPROPAMIDE (DIABINESE) PIOGLITAZONE (ACTOS) Effective 1/1/2012 CANAGLIFLOZIN (INVOKANA) GLIMEPIRIDE (AMARYL) PIOGLITAZONE/GLIMEPIRIDE (DUETACT) Effective 1/1/2012 CANAGLIFLOZIN/METFORMIN (INVOKAMET) GLIPIZIDE (GLUCOTROL) PIOGLITAZONE/METFORMIN (ACTOSPLUS MET) Eff 1/1/2012 DAPAGLIFLOZIN (FARXIGA) GLYBURIDE (DIABETA) ROSIGLITAZONE (AVANDIA) Effective 1/1/2012 DAPAGLIFLOZIN/METFORMIN (XIGDUO XR) GLYBURIDE MICRONIZED (GLYNASE) ROSIGLITAZONE/GLIMEPIRIDE (AVANDARYL) Eff 1/1/2012 DULAGLUTIDE (TRULICITY) METFORMIN/GLIPIZIDE (METAGLIP) ROSIGLITAZONE/METFORMIN (AVANDAMET) Eff 1/1/2012 EMPAGLIFLOZIN (JARDIANCE) METFORMIN/GLYBURIDE (GLUCOVANCE) EXENATIDE (BYETTA) PIOGLITAZONE/GLIMEPIRIDE (DUETACT) Effective 1/1/2012 NON-PREFERRED -- EXENATIDE MICROSPHERES (BYDUREON) TOLAZAMIDE (TOLINASE) INCLUDE BUT NOT LIMITED TO LINAGLIPTIN (TRADJENTA) PIOGLITAZONE (ACTOS)* Effective 1/12/2012 LINAGLIPTIN/METFORMIN (JENTADUETO) NON-PREFERRED -- PIOGLITAZONE/GLIMEPIRIDE (DUETACT)* Effective 1/12/2012 LIRAGLUTIDE (VICTOZA) INCLUDE BUT NOT LIMITED TO PIOGLITAZONE/METFORMIN (ACTOSPLUS MET)* Eff 1/12/2012 PRAMLINTIDE (SYMLIN) PIOGLITAZONE/GLIMEPIRIDE (DUETACT)* Effective 1/1/2012 PIOGLITAZONE/METFORMIN ER (ACTOSPLUS MET XR)* Eff SAXAGLIPTIN (ONGLYZA) 1/1/2012 SAXAGLIPTIN/METFORMIN (KOMBIGLYZE XR) ROSIGLITAZONE (AVANDIA) Effective 1/1/2012 SITAGLIPTIN (JANUVIA) ROSIGLITAZONE/GLIMEPIRIDE (AVANDARYL) Eff 1/1/2012 SITAGLIPTIN/METFORMIN (JANUMET) ROSIGLITAZONE/METFORMIN (AVANDAMET) Eff 1/1/2012 SITAGLIPTIN/METFORMIN EXTENDED RELEASE (JANUMET XR) SITAGLIPTIN/SIMVASTATIN (JUVISYNC) *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 10 of 14

125 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 ENDOCRINE AND METABOLIC AGENTS GASTROINSTESTINAL RENAL AND GENITOURINARY AGENTS ESTROGEN REPLACEMENT AGENTS PROTON PUMP INHIBITORS OVERACTIVE BLADDER AGENTS ORIGINAL POSTED PREFERRED STATUS: 2/14/2006 ORIGINAL POSTED PREFERRED STATUS: 3/18/2005 ORIGINAL POSTED PREFERRED STATUS: 6/16/2006 ORIGINAL EDIT EFFECTIVE DATE: 4/17/2006 ORIGINAL EDIT EFFECTIVE DATE: 5/18/2005 ORIGINAL EDIT EFFECTIVE DATE: 8/15/2006 RE-REVIEW POSTED PREFERRED STATUS: 5/12/2008 RE-REVIEW POSTED PREFERRED STATUS: 1/31/2008 REVISED POSTED PREFERRED STATUS: 5/14/2009 REVISED EDIT EFFECTIVE DATE: 7/11/2008 REVISED EDIT EFFECTIVE DATE: 4/1/2008 REVISED EDIT EFFECTIVE DATE: 7/14/2009 RE-REVIEW POSTED PREFERRED STATUS: 5/6/2013 RE-REVIEW POSTED PREFERRED STATUS: 2/16/2012 PREFERRED REVISED EDIT EFFECTIVE DATE: 7/9/2013 REVISED EDIT EFFECTIVE DATE: 5/8/2012 ESTRADIOL 0.5MG, 1MG, 2MG ORAL TABLET (ESTRACE) RE-REVIEW POSTED PREFERRED STATUS: 5/21/2014 ESTROPIPATE ORAL TABLET (OGEN) PREFERRED REVISED EDIT EFFECTIVE DATE: 5/30/2014 ESOMEPRAZOLE CAPSULE* (NEXIUM) Effective 7/9/2013 NON-PREFERRED -- OMEPRAZOLE 20MG CAPSULE* (Rx PRILOSEC) PREFERRED INCLUDE BUT NOT LIMITED TO PANTOPRAZOLE (PROTONIX)* Effective 7/9/2013 FESOTERODINE (TOVIAZ) Effective 5/30/2014 ESTRADIOL ACETATE TABLET (FEMTRACE) OXYBUTYNIN 5MG/5ML SYRUP, 5MG TABLET (DITROPAN) ESTRADIOL ACETATE VAGINAL RING (FEMRING) NON-PREFERRED -- OXYBUTYNIN ER (DITROPAN XL)* ESTRADIOL ORAL 1.5MG TABLET (ESTRACE) INCLUDE BUT NOT LIMITED TO SOLIFENACIN (VESICARE) ESTRADIOL SPRAY (EVAMIST) DEXLANSOPRAZOLE (DEXILANT) ESTRADIOL TOPICAL GEL (DIVIGEL) ESOMEPRAZOLE CAPSULE (NEXIUM) Effective 7/9/2013 NON-PREFERRED -- ESTRADIOL TRANSDERMAL (ALORA, CLIMARA) ESOMEPRAZOLE/NAPROXEN (VIMOVO) INCLUDE BUT NOT LIMITED TO ESTRADIOL VAGINAL RING (ESTRING) ESOMEPRAZOLE PACKET (NEXIUM PACKET) DARIFENACIN (ENABLEX) ESTRADIOL VAGINAL TABLET (VAGIFEM) ESOMEPRAZOLE STRONTIUM DR CAPSULE FESOTERODINE (TOVIAZ) Effective 5/30/2014 ESTRADIOL/DROSPIRENONE (ANGELIQ)* LANSOPRAZOLE CAPSULE (PREVACID CAPSULE)* FLAVOXATE (URISPAS) ESTRADIOL/LEVONORGESTREL (CLIMARA PRO)* LANSOPRAZOLE SOLUTAB (PREVACID SOLUTAB)* OXYBUTYNIN GEL (GELNIQUE) ESTRADIOL/NORETHINDRONE ACETATE (ACTIVELLA)* OMEPRAZOLE 10MG, 40MG CAPSULE (PRILOSEC) OXYBUTYNIN PATCH (OXYTROL) ESTRADIOL/NORGESTIMATE (PREFEST)* OMEPRAZOLE SUSPENSION (PRILOSEC SUSPENSION) MIRABEGRON ER (MYRBETRIQ) ESTROGENS, CONJUGATED (CENESTIN, ENJUVIA, PREMARIN) OMEPRAZOLE/SODIUM BICARBONATE (ZEGERID) TOLTERODINE IMMEDIATE RELEASE TABLET (DETROL) ESTROGENS, CONGUATED/BAZEDOXIFENE (DUAVEE) PANTOPRAZOLE (PROTONIX) Effective 7/9/2013 TOLTERODINE LA CAPSULE (DETROL LA) ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE RABEPRAZOLE (ACIPHEX) TROSPIUM (SANCTURA) (PREMPHASE, PREMPRO)* TROSPIUM ER (SANCTURA XR) Effective 5/8/2012 ESTROGENS, ESTERIFIED (MENEST) ETHINYL ESTRADIOL/NORETHINDRONE ACETATE (FEMHRT)* *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 11 of 14

126 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 NASAL INHALANT PRODUCTS RESPIRATORY AGENTS RESPIRATORY AGENTS CORTICOSTEROIDS BRONCHODILATORS, SHORT-ACTING BRONCHODILATORS, LONG-ACTING Quick Relief Medications for Asthma Controller Medications for Asthma ORIGINAL POSTED PREFERRED STATUS: 9/29/2006 ORIGINAL EDIT EFFECTIVE DATE: 11/28/2006 ORIGINAL POSTED PREFERRED STATUS: 3/30/2007 ORIGINAL POSTED PREFERRED STATUS: 3/30/2007 REVISED POSTED PREFERRED STATUS: 6/25/2009 ORIGINAL EDIT EFFECTIVE DATE: 5/29/2007 ORIGINAL EDIT EFFECTIVE DATE: 5/29/2007 REVISED EDIT EFFECTIVE DATE: 8/24/2009 RE-REVIEW POSTED PREFERRED STATUS: 5/11/2009 RE-REVIEW POSTED PREFERRED STATUS: 5/11/2009 RE-REVIEW POSTED PREFERRED STATUS: 5/17/2012 RE-REVIEW EDIT EFFECTIVE DATE: 8/11/2009 RE-REVIEW EDIT EFFECTIVE DATE: 8/11/2009 RE-REVIEW EDIT EFFECTIVE DATE: 7/16/2012 RE-REVIEW POSTED PREFERRED STATUS: 12/30/2011 RE-REVIEW POSTED PREFERRED STATUS: 7/21/2014 RE-REVIEW EDIT EFFECTIVE DATE: 4/17/2012 RE-REVIEW EDIT EFFECTIVE DATE: 9/23/2014 RE-REVIEW POSTED PREFERRED STATUS: 7/21/2014 PREFERRED RE-REVIEW EDIT EFFECTIVE DATE: 9/23/2014 PREFERRED FLUTICASONE FUROATE (VERAMYST) Effective 7/16/2012 FLUTICASONE PROPIONATE (FLONASE) NON-PREFERRED -- MOMETASONE (NASONEX) Effective 7/16/2012 PREFERRED INCLUDE BUT NOT LIMITED TO NASACORT AQ (brand only) Effective 1/1/2014 ALBUTEROL 0.83MG/ML & 5MG/ML SOLUTION ACLIDINIUM INHALER (TUDORZA PRESSAIR)* ALBUTEROL INHALER HFA (VENTOLIN HFA 18 GRAM) ARFORMOTEROL INHALATION SOLUTION (BROVANA) NON-PREFERRED -- LEVALBUTEROL HFA INHALER (XOPENEX HFA) Eff 9/23/2014 FORMOTEROL INHALATION SOLUTION (PERFOROMIST) INCLUDE BUT NOT LIMITED TO FORMOTEROL INHALER (FORADIL) AZELASTINE/FLUTICASONE NASAL SPRAY (DYMISTA) NON-PREFERRED -- SALMETEROL INHALER (SEREVENT DISKUS) BECLOMETHASONE (BECONASE AQ, QNASAL) INCLUDE BUT NOT LIMITED TO TIOTROPIUM INHALER (SPIRIVA)* BUDESONIDE (RHINOCORT AQUA) ALBUTEROL 0.21MG/ML, 0.42MG/ML SOLUTION (ACCUNEB) UMECLIDINIUM INHALER (INCRUSE ELLIPTA) CICLESONIDE (OMNARIS, ZETONNA) ALBUTEROL 2.5MG/0.5ML SOLUTION UMECLIDINIUM/VILANTEROL INHALER (ANORO ELLIPTA) FLUTICASONE FUROATE (VERAMYST) Effective 7/16/2012 ALBUTEROL INHALER HFA (PROAIR HFA) Effective 4/17/2012 MOMETASONE (NASONEX) Effective 7/16/2012 ALBUTEROL INHALER HFA (PROVENTIL HFA) NASACORT AQ (brand only) Effective 1/1/2014 ALBUTEROL INHALER HFA (VENTOLIN HFA 8 GRAM) TRIAMCINOLONE (NASOCORT AQ-generic only) Eff 7/16/2012 ALBUTEROL/IPRATROPIUM (ATROVENT HFA, COMBIVENT, COMBIVENT RESPIMAT, DUONEB)* IPRATROPIUM (ATROVENT)* LEVALBUTEROL HFA INHALER (XOPENEX HFA) Eff 9/23/2014 LEVALBUTEROL SOLUTION (XOPENEX) METAPROTERENOL INHALER AND SOLUTION (ALUPENT) PIRBUTEROL INHALER (MAXAIR AUTOHALER) Eff 4/17/2012 *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 12 of 14

127 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS BETA 2 AGONISTS/INHALED CORTICOSTEROIDS INHALED CORTICOSTEROIDS LEUKOTRIENE RECEPTOR ANTAGONISTS Controller Medications for Asthma and COPD Controller Medications for Asthma and COPD Controller Medications for Asthma ORIGINAL POSTED PREFERRED STATUS: 5/11/2009 ORIGINAL POSTED PREFERRED STATUS: 5/12/2006 ORIGINAL POSTED PREFERRED STATUS: 5/11/2009 ORIGINAL EDIT EFFECTIVE DATE: 8/11/2009 ORIGINAL EDIT EFFECTIVE DATE: 7/11/2006 ORIGINAL EDIT EFFECTIVE DATE: 8/11/2009 RE-REVIEW POSTED PREFERRED STATUS: 8/22/2011 REVISED POSTED PREFERRED STATUS: 5/11/2009 RE-REVIEW EDIT EFFECTIVE DATE: 10/25/2011 REVISED EDIT EFFECTIVE DATE: 8/11/2009 PREFERRED RE-REVIEW POSTED PREFERRED STATUS: 7/21/2014 RE-REVIEW POSTED PREFERRED STATUS: 8/22/2011 MONTELUKAST (SINGULAIR)* RE-REVIEW EDIT EFFECTIVE DATE: 9/23/2014 RE-REVIEW EDIT EFFECTIVE DATE: 10/25/2011 RE-REVIEW POSTED PREFERRED STATUS: 7/21/2014 NON-PREFERRED -- PREFERRED RE-REVIEW EDIT EFFECTIVE DATE: 9/23/2014 INCLUDE BUT NOT LIMITED TO BUDESONIDE/FORMOTEROL (SYMBICORT)* ZAFIRLUKAST (ACCOLATE) FLUTICASONE/SALMETEROL (ADVAIR DISKUS)* Eff 9/23/2014 PREFERRED ZILEUTON (ZYFLO) FLUTICASONE/SALMETEROL HFA (ADVAIR HFA)* Eff 9/23/14 BECLOMETHASONE (QVAR)* Effective 9/23/2014 MOMETASONE/FORMOTEROL (DULERA)* BUDESONIDE INHALER (PULMICORT FLEXHALER)* Eff 9/23/14 FLUNISOLIDE (AEROSPAN)* Effective 9/23/2014 NON-PREFERRED -- FLUTICASONE (FLOVENT HFA)* INCLUDE BUT NOT LIMITED TO FLUTICASONE DISK WITH DEVICE (FLOVENT DISKUS)* FLUTICASONE/SALMETEROL (ADVAIR DISKUS) Eff 9/23/2014 MOMETASONE (ASMANEX 30, 60, 120 INHALATION UNITS)* FLUTICASONE/SALMETEROL HFA (ADVAIR HFA) Eff 9/23/14 Effective 9/23/2014 FLUTICASONE/VILANTEROL (BREO ELLIPTA) NON-PREFERRED -- INCLUDE BUT NOT LIMITED TO BECLOMETHASONE (QVAR) Effective 9/23/2014 BUDESONIDE AMPULE (PULMICORT RESPULE)* BUDESONIDE INHALER (PULMICORT FLEXHALER) Eff 9/23/14 CICLESONIDE (ALVESCO) FLUNISOLIDE (AEROSPAN) Effective 9/23/2014 FLUTICASONE FUROATE (ARNUITY ELLIPTA) MOMETASONE (ASMANEX 7,14 INHALATION UNITS) MOMETASONE (ASMANEX 30, 60, 120 INHALATION UNITS) Effective 9/23/2014 TRIAMCINOLONE (AZMACORT) *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 13 of 14

128 Preferred Drug List Prescribers may request an override for non-preferred drugs by calling the UAMS College of Pharmacy Evidence- Based Prescription Drug Program Help Desk at: Toll Free or Local This Preferred Drug List is subject to change without notice. New products in a reviewed drug class are considered NON- PREFERRED until the committee has reevaluated the evidence for the drug class. The effective implementation date stated for each drug class is the date claims will be edited at point-of-sale. For the most up-to-date Preferred Drug List visit 12/23/2014 RESPIRATORY AGENTS DISCLAIMER PHOSPHODIESTERASE INHIBITORS FIBROMYALGIA & NEUROPATHIC PAIN AGENTS Medications for COPD ORIGINAL POSTED PREFERRED STATUS: 4/3/2008 ORIGINAL POSTED PREFERRED STATUS: 7/21/2014 ORIGINAL EDIT EFFECTIVE DATE: 6/5/2008 ORIGINAL EDIT EFFECTIVE DATE: 9/23/2014 The non-preferred antiepileptic medications will be considered nonpreferred for treating fibromyalgia and neuropathic pain only. PREFERRED Medications listed as either preferred or non-preferred status in this category may or may not include an FDA approved indication for NON-PREFERRED -- fibromyalgia or neuropathic pain. Use of these medications for INCLUDE BUT NOT LIMITED TO fibromyalgia, neuralgias, and neuropathic pain has been reviewed ROFLUMILAST (DALIRESP) through the evidence-based review process. Medications listed in this category as either preferred or non-preferred status are not to be construed as endorsements for marketing of off-label use by the manufacturer or by Medicaid. *Please refer to the PDL Criteria Overview for more detail GENERIC (SAMPLE BRAND) LISTED FOR REFERENCE ONLY Strikethrough indicates change in PDL Status Page 14 of 14

129 NAME DATE DIAGNOSIS: Viral respiratory infection n Other: GENERAL INSTRUCTIONS n Get plenty of rest. n Drink more fluids. n Take acetaminophen or ibuprofen for fever or aches. n Do not give aspirin to people under age 19. n Avoid smoking, second-hand smoke and alcohol. n Soothe throat with ice chips or throat spray (throat drops for adults). n Ease congestion with a vaporizer or nasal spray. OTHER TREATMENTS n n n Congestion: Cough: Ear ache: Use medicines as directed by your doctor. Always read the instructions for over the counter medications. SAMPLE FOLLOW UP Call or return to the clinic: n If not improved in days. n If new or changed symptoms occur. n If temperature is greater than. n If you have other concerns. n May return to work/school/day care when fever is gone or on. SIGNED

130 FAST FACTS ON ANTIBIOTICS n Antibiotics don t work for viruses that cause colds, bronchitis and most sore throats. n Using antibiotics against a virus can be harmful. n Overuse of antibiotics creates bacteria that are resistant to antibiotics and difficult to treat. IF YOUR DOCTOR GIVES YOU AN ANTIBIOTIC n Take your antibiotic exactly how your doctor says you should. n Don t share your antibiotic with friends or family. n Take every dose. Don t keep your antibiotic for the next time you are sick. USUAL CAUSE ANTIBIOTIC ILLNESS VIRUS BACTERIA NEEDED? Bronchitis (coughing illness) X NO Chest cold X NO Cold X NO Green/yellow runny nose X NO Middle ear infection X X Sometimes Sinus infection X X Sometimes Sore throat X X Sometimes SAMPLE Save the antibiotic. Don t use it when you don t need it. THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. QP2-ARRX.PAD,4-11/14

131 NOMBRE FECHA DIAGNÓSTICO: Infección respiratoria viral n Otros: INSTRUCCIONES GENERALES n n n n n n n Descanse lo suficiente. Tome más líquidos. Tome acetaminofeno o ibuprofeno para la fiebre o dolores. No le dé aspirina a personas menores de 19 años. Evite fumar, el humo de segunda mano y el alcohol. Alivie el dolor de garganta con trocitos de hielo o aerosol para la garganta (pastillas para los adultos). Alivie la congestión con un vaporizador o aerosol nasal. OTROS TRATAMIENTOS n n n Congestión: Tos: Dolor de oído: Use los medicamentos tal como lo indique su médico. Siempre lea las instrucciones para tomar medicamentos de venta libre. SAMPLE SEGUIMIENTO Llame o regrese a la clínica: n Si no ha mejorado en días. n Si se presentan síntomas nuevos o cambiados. n Si la temperatura es superior a. n Si usted tiene otras preocupaciones. n Puede volver al trabajo/escuela/guardería cuando la fiebre haya desaparecido o el. FIRMADO

132 DATOS RÁPIDOS SOBRE ANTIBIÓTICOS n Los antibióticos no actúan sobre los virus que causan los resfriados, bronquitis y la mayoría de los dolores de garganta. n El tomar antibióticos contra un virus puede ser perjudicial. n El tomar antibióticos en exceso crea bacterias que son resistentes a los antibióticos y difíciles de tratar. SI SU MÉDICO LE RECETA UN ANTIBIÓTICO n Tome su antibiótico exactamente como su médico le dice que debe. n No comparta su antibiótico con amigos o familiares. n Tome todas las dosis. No guarde su antibiótico para la próxima vez que usted está enfermo. CAUSA USUAL NECESITA ENFERMEDAD VIRUS BACTERIAS ANTIBIÓTICOS? Bronquitis (enfermedad con tos) X NO Congestión de pecho X NO Catarro X NO Nariz moquea verde/amarillo X NO Infección del oído medio X X Algunas veces Infección sinusal X X Algunas veces Dolor de garganta X X Algunas veces SAMPLE Salva al antibiótico. No lo uses cuando no lo necesitas. ESTE MATERIAL FUE PREPARADO POR LA FUNDACIÓN ARKANSAS PARA LA ATENCIÓN MÉDICA INC. (AFMC) BAJO CONTRATO CON LA DIVISIÓN DE SERVICIOS MÉDICOS DEL DEPARTAMENTO DE SERVICIOS HUMANOS DE ARKANSAS, LOS CONTENIDOS PRESENTADOS NO REFLEJAN NECESARIAMENTE LA POLÍTICA DEL ADHS. EL DEPARTAMENTO DE SERVICIOS HUMANOS DE ARKANSAS CUMPLR CON LOS TÍTULOS VI Y VII DE LA LEY DE DERECHOS CIVILES. QP2-ARRXS.PAD,4-11/14

133 Breastfeeding is best for both of them. Breastfeeding is best for both of them. can help make it easier. Fewer than one-third of infants born in Arkansas are breastfed six months after birth. 1 The most recent state ranking by the CDC puts us at number 52 in promoting breastfeeding. Breastfeeding is natural but is not always easy. Education and increased support can increase success. Success or failure of breastfeeding promotion efforts can often be traced to the level or lack of administrative support. 2 For more information, the CDC Guide to Breastfeeding Interventions and other resources can be found at Family Doctors and Pediatricians At any prenatal visits and in the hospital, educate mothers about the benefits of breastfeeding and what to expect. Ensure that the hospital staff offers skin-to-skin contact immediately after birth and appropriate support from nurses and/or lactation specialists. At the first post-partum visit: Ask if the mother is still breastfeeding and how it is going. Prescribe vitamin D supplementation for all breastfeeding infants. Assess the infant s weight and address any concerns about whether the baby is getting enough milk. (Any weight loss greater than 7% from birth could be a sign that breastfeeding is not going well.) Ask questions to keep communication open: How often is your baby feeding? How is your milk flowing? Does your baby seem to be latching on well? Remind mothers to eat well and drink plenty of liquids to stay hydrated. If possible, observe the baby feeding to help identify any problems, such as improper or inadequate latch, no swallowing sound, no jaw movement or inability to latch both breasts. can help make it easier. Fewer than one-third of infants born in Arkansas are breastfed six months after birth. 1 The most recent state ranking by the CDC puts us at number 52 in promoting breastfeeding. Breastfeeding is natural but is not always easy. Education and increased support can increase success. Success or failure of breastfeeding promotion efforts can often be traced to the level or lack of administrative support. 2 For more information, the CDC Guide to Breastfeeding Interventions and other resources can be found at Family Doctors and Pediatricians At any prenatal visits and in the hospital, educate mothers about the benefits of breastfeeding and what to expect. Ensure that the hospital staff offers skin-to-skin contact immediately after birth and appropriate support from nurses and/or lactation specialists. At the first post-partum visit: Ask if the mother is still breastfeeding and how it is going. Prescribe vitamin D supplementation for all breastfeeding infants. Assess the infant s weight and address any concerns about whether the baby is getting enough milk. (Any weight loss greater than 7% from birth could be a sign that breastfeeding is not going well.) Ask questions to keep communication open: How often is your baby feeding? How is your milk flowing? Does your baby seem to be latching on well? Remind mothers to eat well and drink plenty of liquids to stay hydrated. If possible, observe the baby feeding to help identify any problems, such as improper or inadequate latch, no swallowing sound, no jaw movement or inability to latch both breasts.

134 At the hospital Hospitals have a critical role in encouraging breastfeeding and increasing long-term success. Though nurses and lactation specialists provide most of the hands-on support, physicians and administrators must set policy and ensure that staff members have the training and resources needed. The UNICEF/WHO Baby Friendly Hospital Initiative ( is now being implemented at hospitals across the United States. The BFHI Ten Steps to Successful Breastfeeding for U.S. hospitals are: ➊ Have a written breastfeeding policy that is routinely communicated to all health care staff. ➋ Train all health care staff in skills necessary to implement this policy. ➌ Inform all pregnant women about the benefits and management of breastfeeding. ➍ Help mothers initiate breastfeeding within one hour of birth. ➎ Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. ➏ Give newborn infants no food or drink other than breastmilk, unless medically indicated. ➐ Practice rooming in allow mothers and infants to remain together 24 hours a day. ➑ Encourage breastfeeding on demand. ➒ Give no pacifiers or artificial nipples to breastfeeding infants. ➓ Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. To be designated by Baby-Friendly USA, hospitals must comply with the International Code of Marketing of Breast Milk Substitutes ( Hospitals should also ensure that HIV status is known at labor and that all maternal medications are compatible with breastfeeding. During discharge, ensure that the baby is scheduled for routine pediatric care within the first week. 1. Breastfeeding Report Card, United States 2010: Outcome Indicators, based on the United States National Immunization Survey, 2007 Births. Centers for Disease Control and Prevention, Department of Health and Human Services. Available at 2. Int J Gynaecol Obstet. 1990;31 Suppl 1:61-5; discussion Available at Make mothers aware of any resources available, such as the Arkansas Breastfeeding Helpline ( ). At the hospital Hospitals have a critical role in encouraging breastfeeding and increasing long-term success. Though nurses and lactation specialists provide most of the hands-on support, physicians and administrators must set policy and ensure that staff members have the training and resources needed. The UNICEF/WHO Baby Friendly Hospital Initiative ( is now being implemented at hospitals across the United States. The BFHI Ten Steps to Successful Breastfeeding for U.S. hospitals are: ➊ Have a written breastfeeding policy that is routinely communicated to all health care staff. ➋ Train all health care staff in skills necessary to implement this policy. ➌ Inform all pregnant women about the benefits and management of breastfeeding. ➍ Help mothers initiate breastfeeding within one hour of birth. ➎ Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. ➏ Give newborn infants no food or drink other than breastmilk, unless medically indicated. ➐ Practice rooming in allow mothers and infants to remain together 24 hours a day. ➑ Encourage breastfeeding on demand. ➒ Give no pacifiers or artificial nipples to breastfeeding infants. ➓ Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. To be designated by Baby-Friendly USA, hospitals must comply with the International Code of Marketing of Breast Milk Substitutes ( Hospitals should also ensure that HIV status is known at labor and that all maternal medications are compatible with breastfeeding. During discharge, ensure that the baby is scheduled for routine pediatric care within the first week. 1. Breastfeeding Report Card, United States 2010: Outcome Indicators, based on the United States National Immunization Survey, 2007 Births. Centers for Disease Control and Prevention, Department of Health and Human Services. Available at 2. Int J Gynaecol Obstet. 1990;31 Suppl 1:61-5; discussion Available at Make mothers aware of any resources available, such as the Arkansas Breastfeeding Helpline ( ). This material was prepared by the Arkansas Foundation for Medical Care Inc. (AFMC) under contract with the Arkansas Department of Human Services, Division of Medical Services. The contents presented do not necessarily reflect Arkansas DHS policy. The Arkansas Department of Human Services is in compliance with Titles VI and VII of the Civil Rights Act. QP2-BFP.CAR, 1-3/11 This material was prepared by the Arkansas Foundation for Medical Care Inc. (AFMC) under contract with the Arkansas Department of Human Services, Division of Medical Services. The contents presented do not necessarily reflect Arkansas DHS policy. The Arkansas Department of Human Services is in compliance with Titles VI and VII of the Civil Rights Act. QP2-BFP.CAR, 1-3/11

135 Cervical Cancer Screening Guidelines Summary WHAT S NEW INITIAL SCREENING All women should begin cervical cancer screening at age 21. Women under the age of 21 should NOT be screened regardless of their age of first sexual contact unless they have a high-risk condition, such as HIV. WOMEN AGES Women of this age should receive cervical cancer screening once every 3 years using either a conventional pap smear or a liquid-based cytology method. HPV testing should not be performed for the purpose of screening in this age range. WOMEN AGES Women of this age should receive co-testing for cervical cancer screening. Co-testing combines cytology (conventional or liquid based) with HPV testing. The recommended screening interval is every five years. Cytology (conventional or liquid based) without HPV testing is also acceptable for screening of women in this age group, but should be done every three years. WOMEN AGES 65 YEARS AND OLDER Women of this age should not be screened if they have had adequate prior screening and no history of CIN or cervical cancer within the last 20 years. Hysterectomy: Women who have had a hysterectomy with removal of the cervix for benign reasons and with no history of abnormal or cancerous cell growth may discontinue routine cervical cancer screening. Women who have had a hysterectomy who have had previous cervical cancer or CIN should continue to receive individualized testing. More frequent or earlier (under age 21) cervical cancer screening may be indicated for high-risk women, such as patients with HIV, patients who are immunosuppressed or patients who were exposed to DES in utero. Testing should be individualized. HPV Vaccine: An HPV vaccine is recommended for all girls, ages The CDC states that girls as young as nine years of age may receive the vaccine; however, the provider should be aware that insurance plans may not cover the vaccine in 9-11-year-old patients. Ideally, the vaccine should be administered to girls before they reach an age when they might be exposed to HPV. The HPV vaccine is not recommended for pregnant women. At this time, cervical cancer screening is the best approach to prevent cervical cancer. Recommendations for cervical cancer screening apply regardless of the patient s HPV vaccination status.

136 CERVICAL CANCER SCREENING GUIDELINES SUMMARY Pap collection procedure PAP COLLECTION PROCEDURE Cytology specimens should be collected using a broom or a brush-spatula technique. If using a broom device with a liquid-based method, follow the manufacturer s specifications. If using a brush-spatula technique, an extended tip spatula is recommended. The brush should be inserted in to the endocervix first and rotated one-half turn. The cells should be applied to a glass slide and spray-fixed immediately. Repeat the procedure with the extended-tip spatula. Avoid excessive force as this may produce bleeding, which may obscure the specimen. A single slide may be used at the discretion of the clinician rather than using two slides. A Pap smear that is performed on a pregnant patient uses the same technique except that some clinicians may prefer to use a Dacron swab instead of an endocervical brush. REMINDER These recommendations apply only to screening situations; that is, for patients who have no current evidence or history of CIN or cervical cancer. Please refer to other guidelines for follow-up and testing of patients who have had abnormal cytologic screening, positive HPV testing or a diagnosis of CIN or cervical cancer. PLEASE NOTE Cervical cancer screening should not be used as a substitute test for other sexually transmitted diseases. However, specimens collected using liquid-based techniques may also be tested for HPV, gonorrhea and chlamydia by some laboratories. SOURCE: org/cgi/content/short/52/6/342 THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC), THE MEDICARE QUALITY IMPROVEMENT ORGANIZATION FOR ARKANSAS, UNDER CONTRACT THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICIES. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. QB2-CC.FLY,1-3/13

137 Smoking Cessation: Effective for dates of service on or after June 15, 2014, the following procedure codes will be payable for all ages for Tobacco Cessation counseling to Certified Nurse Midwife, Nurse Practitioner and Physician providers. No coverage criteria have changed. Existing procedure code 99406, modifier SE, must be used for one 15-minute unit of service and procedure code 99407, modifier SE, must be used for one 30-minute unit of service. These codes will be billable on paper or on electronic claims. ( )This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the service. When using a procedure code with this symbol, the service must meet the indicated Arkansas Medicaid description. Current Procedure Code Current Modifier Replacement Code Replacement Modifier Arkansas Medicaid Description SE SE (Smoking and tobacco use cessation counseling visit; intermediate, 15- minutes) SE SE (Smoking and tobacco use cessation counseling visit; intensive, 30-minutes)

138 Arkansas Department of Human Services Division of County Operations THIRD PARTY RESOURCE / MEDICAL INSURANCE A. APPLICANT INFORMATION: 1. Last Name 2. First Name 3. MI 4. Sex 5. Social Security Number 6. Applicant s Address 7. City 8. ST 9. Zip 10. Other than Medicare, do you have health insurance or some other insurance, settlement, person or group that is responsible for paying all or part of your medical expenses? Yes If Yes, please either attach proof of coverage (such as a copy of your insurance card) OR complete B, C and D below. No If No, please skip to Section F and provide a phone number, sign and date the form, and mail it to us. B. POLICYHOLDER INFORMATION: 11. Policyholder s Last Name 12. First Name 13. MI 14. Social Security Number 15. Policyholder s Address 16. City 17. ST 18. Zip C. INSURANCE INFORMATION: 19. Name of Insurance Company 20. Policy Number 21. Policy Effective Dates From / / To / / 22. Address of Claims Office 23. City 24. ST 25. Zip 26. Check all Type of Benefits/Coverage Applicable (at least one must be checked) 1. Medical 4. Vision 2. Pharmacy 5. Medicare Supplement 3. Dental 6. Long Term Care 7. Indemnity/Hospital/Cancer/Heart 8. Accident Only (non-auto) 9. Automobile/Motorcycle Accident 10. Other D. INDICATE ALL INDIVIDUALS COVERED BY POLICY: 27. Last Name 28. First 29. MI 30. Relationship 31. SSN or Medicaid Number E. COMMENTS F. TELEPHONE NUMBER WHERE YOU CAN BE REACHED BETWEEN 8:00/4:30 AUTHORIZATION AND ASSIGNMENT I authorize any holder of medical or other information about me to release information needed for this or a related Medicaid claim to the Arkansas Medicaid program. I authorize the further release of any such information to any other parties who may be liable for any of my medical expenses. I hereby authorize and request that funds, settlement or other payments made by or on behalf of third parties, including tort-feasors or insurers, arising out of this Medicaid claim be paid directly to the Arkansas Medicaid program. I also assign all rights in any settlement made by me or on my behalf and arising out of any claim of which this is a part to the extent of medical expenses paid by Medicaid whether or not a portion of such settlement is designated as being for medical expenses. Any such funds received by me shall be paid to the Arkansas Medicaid program. I permit a copy of this authorization to be used in place of the original. Applicant/Recipient signature (or parent/guardian if minor) Date DCO-662 (rev. 01/14)

139 DHS County Office Only below: Fold in half or tape ends together and Mail to Third Party Liability Unit Division of Medical Services Third Party Liability Unit P.O. Box 1437, Slot S296 Little Rock, AR