Benefit: Pharmacy

Definition: Medications prescribed by a physician to cure a disease or illness or prevent an infection. Medicaid covers most medications used in outpatient settings, including injectable drugs. Most medications included on the Medicaid Preferred Drug List (PDL) are available without prior authorization (PA). Medications not on the PDL require PA.

Limits:  Medicaid does not reimburse pharmacies for the following products:

• Anorectics (unless prescribed for an indication other than obesity);
• Cough and cold combination medications for recipients age 21 and older;
• DESI ineffective drugs as designated by the Centers for Medicare and Medicaid Services (CMS);
• Drugs for patients who are hospitalized or being treated in outpatient hospital facilities or ambulatory surgical centers;
• Drugs to treat the terminal condition of hospice recipients;
• Drugs used to treat infertility;
• Experimental drugs;
• Erectile Dysfunction Drugs;
• Hair growth restorers and other drugs for cosmetic use;
• Immunizations for non-Child Health Check-Up recipients 21 years of age and older, except for influenza and pneumoccas vaccines for institutionalized recipients
• Prostheses, appliances and devices (except products for diabetics and products used as contraceptives);
• Vitamins (except prenatal vitamins for pregnant and lactating women and folic acid as a single entity; one vitamin or vitamin/mineral prescription monthly for dialysis patients, fluoridated pediatric vitamins for children 12 years of age or younger); and prescribed ferrous sulfate, gluconate, or fumarate for non-institutionalized patients (ferrous sulfate, gluconate, or fumarate if they are available as floor stock to institutionalized patients) and
• All other over-the-counter products not specified above.

Drugs must be prescribed for medically accepted indications.

Medicaid does not reimburse for drugs not included in a manufacturer’s rebate agreement. Drugs must be prescribed for medically accepted indications.

PA is required for Actiq®, albumin, Aranesp®, Botox®, Cytogam®, Fuzeon®, growth hormone for adults with growth hormone deficiency, immune globulins, Leukine®, Neupogen®, Neurontin®, Neulasta®, Neutrexin®, Orfandin®, Oxycontin®, Panretin®, Proleukin®, Provigil®, Procrit®, Serostim®, Targretin® gel and capsules, Regranex® in long-term care facilities, Vfend®, Valycte®, Xenical®, Venofer®, and adult human growth hormone for HIV/AIDS. HIV/AIDS medications are exempt from PDL restrictions.

PA is required for all prescribed drugs that are not on the PDL. Anti-retrovirals for HIV/AIDS are exempt from PDL restrictions.

Medicaid processes all prescription claims through Drug Utilization Review (DUR) and will not reimburse for prescriptions that are refilled too often or too soon, that duplicate other prescriptions, or that result in excessively high dosages for the recipient.

Exceptions:  A provider must request and receive authorization for all exception drugs not on the PDL.

Co-pays: None

Reform items that can vary: # of RX; total annual amount; and plans may vary the medications allowed. Beneficiaries who suffer from chronic conditions may need to verify that the medications they use to treat or manage their health condition are included in a health plan’s formulary (list of authorized medications).