Provider Manuals

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Dental 

Note: The fee schedules for the EPSDT Dental, EDSPW and Adult Denture Programs have been updated for dates of service on or after November 1, 2006. To access the current schedules, click on the link entitled “Fee Schedules”. The revised schedules may be printed for your convenience. The fee schedules located in the Appendix section of the online Dental Service Manual are not current. These schedules will be revised at a later date.

• Dental Program Claims Filing, Chapter 7(E) - Issue Date May, 1, 2003

• Dental Services Policy Manual, Chapter 16 - Issue Date May 1, 2003

Pharmacy

• Pharmacy Benefits Management Services, Chapter 37 - Updated August 15, 2007

• Appendix A - List of Drugs Payable on Drug File

• Appendix B - List of DESI Drugs by National Drug Code (NDC)

• Appendix C - Medicaid Drug Federal Rebate Participating Pharmaceutical Companies

• Appendix D - Point of Sale User Guide

• Appendix E - List of Medications and Correct Decimal Quantities - Updated August 15, 2007

• Appendix F - RXPA Form - Prescribers use to request drug Prior Authorizations

• Appendix G - Universal Drug Claim Form and Instructions

• Appendix H - Form 211 - Drug Adjustment/Void Form and Instructions

• Appendix I - PA01 Form - TPN Prior Authorization Form

• Appendix J - CMS 1500 - To be used in submitting TPN Claims  and CMS 1500 Instructions

• Appendix K - Form 213 - TPN Adjustment/Void Form and Instructions