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PDFWAC 182-530-2000

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.
(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 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 and prescription drugs to promote tobacco/nicotine cessation.
(h) The following generic products for the treatment of cough and cold:
(i) Dextromethorphan 15 mg/5 ml liquid or syrup;
(ii) Dextromethorphan/Guaifenesin 10 mg - 100/5 ml liquid or syrup, including sugar-free formulations;
(iii) Guaifenesin 100 mg/5 ml liquid or syrup;
(iv) Phenylephrine 10 mg tablets;
(v) Phenylephrine 2.5 mg/ml liquid or syrup;
(vi) Pseudoephedrine 30 mg and 60 mg tablets;
(vii) Pseudoephedrine 15 mg/5 ml liquid or syrup; and
(viii) Saline 0.65% nasal spray.
(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 and section 1927, (42 U.S.C. 1396r-8) (d)(2)(D) and (G), (d)(7)(A), (k)(4). WSR 19-22-016, § 182-530-2000, filed 10/25/19, effective 11/25/19. 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.]
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