Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid agency covers:
(a) Outpatient drugs, including
over-the-counter (OTC) drugs, as defined in WAC
182-530-1050, subject to the
limitations and requirements in this chapter, when:
(i) The drug is approved by the Food and Drug
Administration (FDA);
(ii) The drug
is for a medically accepted indication as defined in WAC
182-530-1050;
(iii) The drug is not excluded from coverage
under WAC
182-530-2100;
(iv) The manufacturer has a signed drug
rebate agreement with the federal Department of Health and Human Services
(DHHS). Exceptions to the drug rebate requirement are described in WAC
182-530-7500; and
(v) The drug is prescribed by a provider with
prescriptive authority. Exceptions to the prescription requirement exist for
family planning and emergency contraception in (b) of this
subsection.
(b) Family
planning drugs, devices, and drug-related supplies per chapter 182-532 WAC and
as follows:
(i) OTC family planning drugs,
devices, and drug-related supplies without a prescription when the agency
determines it necessary for client access and safety;
(ii) Family planning drugs that do not meet
the federal drug rebate requirement in WAC
182-530-7500 on a case-by-case
basis; and
(iii) Contraceptive
patches, contraceptive rings, and oral contraceptives, excluding emergency
contraception, when dispensed in a one-year supply only, unless:
(A) A smaller supply is directed by the
prescriber;
(B) A smaller supply is
requested by the client;
(C) The
pharmacy does not have adequate stock.
(c) Vitamins, minerals, and enzymes when
prescribed for:
(i) Prenatal vitamins, when
prescribed and dispensed to pregnant women;
(ii) A medical condition caused by a
clinically documented deficiency;
(iii) A United States Preventive Services
Task Force recommendation with an A or B rating;
(iv) Fluoride for clients under age
twenty-one; or
(v) A clinically
documented medical condition that causes vitamin, mineral, or enzyme
deficiencies, and the deficiency cannot be treated through other dietary
interventions.
(d) OTC
drugs, vitamins, and minerals when determined by the agency to be the least
costly therapeutic alternative for a medically accepted indication. All covered
OTC products determined to be the least costly therapeutic alternatives for
medically accepted indications will be included on the agency's published apple
health preferred drug list. This subsection does not apply to products
prescribed for the treatment of cough or cold symptoms. See this subsection (1)
(h) of this section and WAC
182-530-2100(1)(b)(v)
for coverage of products prescribed for the treatment of cough and cold
symptoms.
(e) Drug-related devices
and drug-related supplies as an outpatient pharmacy benefit when:
(i) Prescribed by a provider with prescribing
authority;
(ii) Essential for the
administration of a covered drug;
(iii) Not excluded from coverage under WAC
182-530-2100; and
(iv) Determined by the agency that a product
covered under chapter 182-543 WAC related to medical equipment and supplies
should be available at retail pharmacies.
(f) Preservatives, flavoring, or coloring
agents, only when used as a suspending agent in a compound.
(g) OTC and prescription drugs to promote
tobacco/nicotine cessation.
(h) For
the treatment of cough and cold, only those products included with a preferred
status on the apple health preferred drug list (PDL), as described in WAC
182-530-4100, on the date a
client's prescription is dispensed.
(2) The agency does not reimburse for any
drug, device, or drug-related supply not meeting the coverage requirements
under this section.
11-14-075, recodified as §182-530-2000, filed
6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.04.050,
74.08.090, SSA § 1927 (
42 U.S.C.
1396r - 8(d)(2)(D)), and 2009 c 564 §
1109. 09-22-005, § 388-530-2000, filed 10/22/09, effective 11/22/09.
Statutory Authority:
RCW
74.04.050,
74.08.090,
74.09.530, and
74.09.700. 09-05-007, §
388-530-2000, filed 2/5/09, effective 3/8/09. Statutory Authority:
RCW
74.04.050,
74.08.090,
74.09.700, 2008 c 245. 08-21-107,
§ 388-530-2000, filed 10/16/08, effective 11/16/08. Statutory Authority:
RCW
74.04.050,
74.08.090,
74.09.530, and
74.09.700. 07-20-049, §
388-530-2000, filed 9/26/07, effective
11/1/07.
