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PDFWAC 182-530-2100

NoncoveredOutpatient drugs and pharmaceutical supplies.

(1) The medicaid agency does not cover:
(a) A drug that is:
(i) Not approved by the Food and Drug Administration (FDA); or
(ii) Prescribed for a nonmedically accepted indication, including diagnosis, dose, or dosage schedule that is not evidenced-based.
(b) A drug prescribed:
(i) For weight loss or gain;
(ii) For infertility, frigidity, impotency;
(iii) For sexual or erectile dysfunction;
(iv) For cosmetic purposes or hair growth; or
(v) For treatment of cough or cold symptoms, except as listed in WAC 182-530-2000 (1)(i).
(c) Drugs used to treat sexual or erectile dysfunction, in accordance with section 1927 (d)(2)(K) of the Social Security Act, unless such drugs are used to treat a condition other than sexual or erectile dysfunction, and these uses have been approved by the Food and Drug Administration.
(d) Drugs listed in the federal register as "less-than-effective" ("DESI" drugs) or which are identical, similar, or related to such drugs.
(e) Outpatient drugs for which the manufacturer requires as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or manufacturer's designee.
(f) A product:
(i) With an obsolete National Drug Code (NDC) for more than two years;
(ii) With a terminated NDC;
(iii) Whose shelf life has expired; or
(iv) Which does not have an eleven-digit NDC.
(g) Over-the-counter (OTC) drugs, vitamins, and minerals, except as allowed under WAC 182-530-2000 (1)(i).
(h) Any drug regularly supplied by other public agencies as an integral part of program activity (e.g., immunization vaccines for children).
(i) Free pharmaceutical samples.
(2) A noncovered drug can be requested through the exception to rule process as described in WAC 182-501-0160.
(3) If a noncovered drug is prescribed through the early and periodic screening, diagnosis, and treatment (EPSDT) process, an authorization request may be submitted indicating that the request is EPSDT related, and the request will be evaluated according to the process in WAC 182-501-0165. (See WAC 182-534-0100 for EPSDT rules.)
[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, § 182-530-2100, filed 10/25/19, effective 11/25/19. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-17-071, § 182-530-2100, filed 8/16/16, effective 9/16/16. Statutory Authority: RCW 41.05.021. WSR 13-18-035, § 182-530-2100, filed 8/28/13, effective 9/28/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-530-2100, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-530-2100, 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, § 388-530-2100, 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, § 388-530-2100, 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, § 388-530-2100, 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, § 388-530-2100, filed 9/26/07, effective 11/1/07.]
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