MAD covers medically necessary prescription drugs and some
over-the-counter drugs, subject to the limitations and restrictions delineated
in this section of this rule. Claims for injectable drugs, intravenous (IV)
admixtures, IV nutritional products and other expensive medications may be
reviewed for medical necessity before or after reimbursement. Providers must
consult MAD, or its designated contractor, before supplying items not
specifically listed in this policy or billing instructions. Drug restrictions
include dosage, day supply, and refill frequency limits necessary to ensure
appropriate utilization or to prevent fraud and abuse. In establishing such
limits, professional standards are considered.
A. For a MAP eligible recipient 21 years of
age and older not in an institution, coverage of over-the-counter items is
limited to insulin, diabetic test strips, prenatal vitamins,
electrolyte replacement system, ophthalmic lubricants, pediculosides and
scabicides, sodium chloride for inhalations, topical and vaginal antifungals
and topical anti-inflammatories. MAD, or its designee, may expand the list of
covered over-the-counter items after making a specific determination that it is
overall more economical to cover an over-the-counter item as an alternative to
prescription items or when an over the counter item is a preferred therapeutic
alternative to prescription drug items. Such coverage is incorporated as part
of the generic-first coverage provisions. Otherwise, the MAP eligible recipient
21 years and older, or his or her authorized representative is responsible for
purchasing or otherwise obtaining an over-the-counter item. Prior authorization
for coverage of other over the counter products may be requested when a
specific regimen of over the counter drugs is required to treat chronic disease
conditions.
B. When drugs are
provided through a preferred drug list, drugs are subject to generic-first
coverage provisions. The MAP eligible recipient must first use one or more
generic items available on the preferred drug list to treat a condition before
MAD covers a brand name drug for the condition. MAD publishes a list of the
therapeutic categories of drug items that are exempt from the generic-first
coverage provisions. Brand name drug items may be covered upon approval by MAD,
or its designee, including HSD contracted managed care organization (MCO),
based upon medical justification by the prescriber. Generic-first provisions do
not apply to injectable drug items.
