Welcome to the Clinical Criteria Page
This page provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. The effective dates for using these documents for clinical reviews are communicated through the Provider notification process.
To determine if a code requires authorization, use the Prior Authorization lookup tool
The Arkansas Medicaid state-specific clinical criteria information is alphabetized below. Not all drugs requiring authorization have Arkansas Medicaid State specific criteria. If a code requires authorization and the clinical criteria document is not found in the list below, please utilize the following link for additional criteria. Clinical Criteria
Arkansas Specific Policies
| Clinical Criteria | Associated Medications (as applicable) | Document Number | Coding |
|---|---|---|---|
| Immunoglobulins | Gammagard® Liquid vial,Gamunex-C® vial,Hizentra® vial (NOT SYRINGE), Asceniv™ vial,Bivigam® vial,Cutaquig® vial,Cuvitru® vial,Cytogam® vial,Flebogamma Dif® vial,Gamastan® S-D vial,Gamastan® vial,Gammagard® S-D vial,Gammaked™ vial,Gammaplex® vial,Hizentra® syringe,HyperRHO® S-D syringe,Hyqvia® vial,Hyqvia IG Component® vial,MICRhoGAM® Ultra-filtered plus syringe,Octagam® vial,Panzyga® vial,Privigen® vial,RhoGAM® Ultra-filtered plus syringe,Rhophylac® syringe,WinRho® SDF vial,Xembify® vial | AR CAID-0003 | 90281, 90283, 90284, J1459, J1460, J1555, J1556, J1557, J1558, J1559, J1560, J1561, J1566, J1568, J1569, J1572, J1575, J1599, J1554, J1551, S9338 |
| Synagis | Synagis | AR CAID-0007 | 90378, S9562 |
(Note: in the case of a clinical criteria document being listed on both sites, please utilize those listed directly above.)
If you have questions or feedback, please contact druglist@carelon.com.