Section 35. Requirements relating to payment for covered outpatient drugs for the categorically needy

A. Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.

The Medicaid agency provides coverage for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses to all Medicaid recipients, including full benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit-Part D. The following excluded drugs are covered:

1. Agents when used for anorexia, weight loss, or weight gain (see specific drug categories in subsection B of this section);

2. Agents when used for the symptomatic relief of cough and colds (see specific drug categories in subsection B of this section);

3. Prescription vitamins and mineral products, except prenatal vitamins and fluoride (see specific drug categories in subsection B of this section); and

4. Nonprescription drugs (see specific drug categories in subsection B of this section).

B. Coverage of specific categories of excluded drugs will be in accordance with existing Medicaid policy as described in 12VAC30-50-520.

Historical Notes

Derived from Volume 23, Issue 11, eff. March 7, 2007; amended, Virginia Register Volume 32, Issue 01, eff. October 22, 2015.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC 1396 et seq.