Family and Children's Medicaid MA-3540 Medicaid Covered Services
XXII. PRESCRIPTION DRUGS
Refer to DMA’s website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for specific coverage criteria, prior approval requirements, and service limitations.
A. Covered Services
1. The prescribed drug must have Federal Drug Administration (FDA) approved indications.
2. The prescribed drug must bear the federal legend statement.
3. A legend drug must be manufactured by a company that has signed a National Medicaid Rebate Agreement with the Centers for Medicare and Medicaid Services (CMS).
4. Selected over–the-counter (OTC) medications and insulin products are covered.
5. Routine immunizations, flu vaccine, DPT immunization, etc.
B. Non-Covered Services
1. OTC drugs (except Insulin and selected OTC products per General Medical Policy No. A-2).
2. Federal Legend drugs or their generic equivalents that are on the DESI list established by the FDA.
3. Any drug manufactured by a company who has not signed a rebate agreement.
4. Medical supplies or devices: needles, syringes, catheters, IV sets, TED hose, etc.
REVISED 08/01/11 – CHANGE NO. 14-11
6. Fertility drugs.
7. Drugs used for cosmetic indications.
8. Durable medical equipment (DME): (Oxygen concentrators, wheelchairs, etc.)
9. IV fluids (Dextrose 500 ml or greater) and irrigation fluids used by Medicaid recipients in an inpatient facility (Must be billed by the facility as ancillary services).
10. Erectile Dysfunction drugs.
11. Weight loss and weight gain drugs.
NOTE: Relative to all services, products, or procedures specified above and for recipients under the age of 21 in regard to EPSDT requirements, see I. and XXXVIII. of this manual section.
1. Medicaid recipients are limited to eight prescriptions each month except as noted in II.B. above. At the discretion of the pharmacist, the monthly prescription limit may be overridden with three additional prescriptions per recipient per month.
2. Medicaid recipients who are entitled to or enrolled in Medicare Part A and/or B have no prescription drug coverage through Medicaid. These recipients must enroll in a prescription drug plan or have other prescription drug coverage.
3. Medicaid recipients requiring more than 11 prescriptions per month are restricted to a single pharmacy each month except for emergencies. Recipients under 21 years of age, recipients in a nursing facility receiving a skilled level of care, recipients in an intermediate care facility/mental retardation center and recipients residing in assisted living facilities and group homes are EXEMPT from the pharmacy opt-in program.
4. Pharmacies participating in Medicaid are required to substitute generic drugs for brand name or trade name drugs unless the prescriber specifically orders the brand name drug by personally indicating in his own handwriting on the prescription order “medically necessary”.
5. The maximum days supply for all drugs is a 34-day supply unless the medication meets the criteria described below to obtain a 90-day supply:
a. A generic, non-controlled, maintenance medication when the recipient has had a previous 30-day fill of the same medication.
REVISED 08/01/11 – CHANGE NO. 14-11
(XXII. C. 5)
b. Birth control medications.
c. Prepackaged hormone replacement therapies.
6. Some medications may have limitations such as age, gender or amount.
D. Prior Approval
1. Prior approval is required for certain drugs prescribed to Medicaid recipients.
2. It is the responsibility of the prescribing physician to obtain approval through DMA’s contracted Pharmacy Benefits Manager (PBM).
1. $3.00 generic drug and selected over-the-counter medications
$3.00 per brand name drug
2. Copayments apply to all Medicaid recipients except as noted in II. E.
3. Recipients residing in assisted living facilities, Adult Care Homes (ACH), and rest homes pay copayments as stated above.