182-530-1075  <<  182-530-2000 >>   182-530-2100

CoveredOutpatient drugs, devices, and drug-related supplies.

(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, and for OTC drugs that promote smoking cessation in (g) 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. The agency will maintain and publish a list of the covered OTC drugs available to clients which have been determined to be the least costly therapeutic alternatives for medically accepted indications. This subsection (1)(d) of this section does not apply to products prescribed for the treatment of cough or cold symptoms. See (1)(i) under this subsection 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 durable 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 drugs, without a prescription, to promote smoking cessation only for clients age eighteen or older and participating in an agency-approved smoking cessation program. Limitation extensions as described in WAC 182-501-0169 are prohibited for the age and counseling requirements in this section.
(h) Drugs prescribed to promote smoking cessation only for clients participating in an agency-approved smoking cessation program, or for clients who are pregnant with a verifiable estimated due date and receiving smoking cessation counseling from the prescribing provider. Limitation extensions as described in WAC 182-501-0169 are prohibited for the age and counseling requirements in this section.
(i) For the treatment of cough and cold symptoms:
(i) Only the following generic, single ingredient formulations:
(A) Guaifenesin 100 mg/5 ml liquid or syrup;
(B) Dextromethorphan 15 mg/5 ml liquid or syrup;
(C) Pseudoephedrine 30 mg or 60 mg tablets;
(D) Saline nasal spray 0.65%; and
(ii) Generic combination product dextromethorphan-guaifenesin 10-100 mg/5 ml syrup, including sugar-free formulations.
(2) The agency does not reimburse for any drug, device, or drug-related supply not meeting the coverage requirements under this section.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-17-071, § 182-530-2000, filed 8/16/16, effective 9/16/16. WSR 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. WSR 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. WSR 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. WSR 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. WSR 07-20-049, § 388-530-2000, filed 9/26/07, effective 11/1/07.]