Prescription Drugs: Coverage And Limitations

01. General Drug Coverage. Medicaid covers prescription drugs not excluded under this rule that are legally obtainable by the order of a prescriber under Section 54-1705A, Idaho Code. (7-1-26) 02. Preferred Drug List (PDL). (7-1-26) a. The PDL identifies preferred drugs and non-preferred drugs within a therapeutic class designated by the Department and reviewed by the Pharmacy and Therapeutics Committee (P&T Committee). (7-1-26) b. A brand name drug may be designated as a preferred drug by the Department if the net cost of the brand name drug after consideration of all rebates is less than the cost of the generic equivalent. (7-1-26) c. The Director makes final decisions regarding the designated preferred or non-preferred status of drugs based on therapeutic recommendations from the P&T Committee and cost analysis from the Medicaid Pharmacy Program. (7-1-26) 03. Covered Drug Products. Medicaid provides coverage to participants for the following drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Section 1927(d)(2) of the SSA: (7-1-26) a. Agents, when used to promote smoking cessation. (7-1-26) b. Prescription vitamins and mineral products. Covered agents include the following: (7-1-26) i. Injectable vitamin B12 (cyanocobalamin and analogues); (7-1-26) ii. Vitamin K and analogues; (7-1-26) iii. Prescription vitamin D and analogues; (7-1-26) iv. Prescription pediatric vitamins, minerals, and fluoride preparations; (7-1-26) v. Prenatal vitamins for pregnant or lactating individuals; and (7-1-26) vi. Prescription folic acid and oral prescription drugs containing folic acid in combination with vitamin B12 or iron salts, or both, without additional ingredients. (7-1-26) c. Certain prescribed non-prescription products, including the following: (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 213 Page 63 i. Permethrin; (7-1-26) ii. Oral iron salts; (7-1-26) iii. Disposable insulin syringes and needles; and (7-1-26) iv. Insulin. (7-1-26) d. Barbiturates. (7-1-26) e. Benzodiazepines. (7-1-26) 04. Additional Criteria for Coverage. The Director, acting upon the recommendation of the P&T Committee, may determine a non-prescription drug product is covered that is therapeutically interchangeable with prescription drugs in the same pharmacological class following evidence-based comparisons of efficacy, effectiveness, clinical outcomes, and safety, and the product is deemed to be a cost-effective alternative. (7-1-26) 05. Excluded Drug Products. Medicaid excludes from coverage the following drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Section 1927(d)(2) of the SSA: (7-1-26) a. Agents, when used for the symptomatic relief of cough and colds. (7-1-26) b. Agents, when used for the treatment of obesity. (7-1-26) c. Covered outpatient drugs for which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee. (7-1-26) d. Agents, when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration (FDA). (7-1-26) 06. Additional Excluded Drugs. Drugs are not covered when ineligible for federal financial participation. (7-1-26) 07. Limitation of Quantities. Medication refills provided before at least seventy-five percent (75%) of the estimated days' supply has been utilized are not covered, unless an increase in dosage is ordered. Days' supply is the number of days a medication is expected to last when used at the dosage prescribed for the participant. No more than a thirty-four (34) days' supply of continuously required medication is to be purchased in a calendar month because of a single prescription except: (7-1-26) a. Providers may be reimbursed for up to a three (3) month supply of select medications or classes of medications for a participant who has received the same dose of the same select medication or class of medications for two (2) months or longer. The Director, acting upon the recommendation of the P&T Committee, approves the list of covered maintenance medications, which targets medications that are administered continuously rather than intermittently, are used most commonly to treat a chronic disease state, and have a low probability for dosage changes. The list of covered maintenance medications is available on the Medicaid Pharmacy website at http:// medicaidpharmacy.idaho.gov. (7-1-26) b. Contraceptive products may be dispensed in a quantity sufficient for up to six (6) months. (7-1-26)