23 Miss. Code. R. 214-1.3

Current through December 10, 2024

Rule 23-214-1.3 - Drugs Subject to Exclusion or Otherwise Restricted

A. The Division of Medicaid does not cover pharmacy benefits for full benefit, dual eligible individuals who are entitled to receive Medicare benefits under Part A, B, or C, except for drugs in the Medicare excluded categories.

B. Medicaid excluded or otherwise restricted drugs include, but are not limited to:

1. Drugs when used for anorexia, weight loss, or weight gain, except selected drugs used to treat obesity.

2. Drugs when used to promote fertility,

3. Drugs when used for cosmetic purposes or hair growth,

4. Over-the-counter (OTC) items except those listed on the Division of Medicaid's OTC formulary which are assigned an appropriate National Drug Code (NDC) on their label and are manufactured by a company that has signed a rebate agreement,

5. Drugs when used for the symptomatic relief of cough and colds except for cough and/or cold drugs listed on the OTC formulary and benzonatate,

6. Prescription vitamins and mineral products except for:

a) Prenatal vitamins,

b) Folic acid, and

c) Cyanocobalamin (vitamin B12) injections.

7. Covered outpatient drugs which the manufacturer requires, as condition of sale, that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee,

8. Those drugs designated less than effective by the Federal Drug Administration (FDA) as a result of the Drug Efficacy Study Implementation (DESI) program unless provided through expanded EPSDT services in Miss. Admin. Code Part 223.

9. [Deleted eff. 01/01/2014],

10. [Deleted eff. 01/01/2014],

11. Drugs when used for the treatment of sexual or erectile dysfunction, unless such drugs are used to treat a condition, other than sexual or erectile dysfunction, for which the drugs have been approved by the FDA.

12. Drugs that are investigational or approved drugs used for investigational purposes,

13. Drugs used for off-label indications which are not found in official compendia or generally accepted in peer reviewed literature,

14. Drugs dispensed after the expiration date,

15. Drugs classified as herbal and/or homeopathic products,

16. Moved to Miss. Admin. Code Part 214, Chapter 1, Rule 1.3.C,

17. Drugs produced by manufacturers that do not have signed rebate agreements with the federal government as required by the Omnibus Budget Reconciliation Act (OBRA) of 1990, unless provided through expanded EPSDT services in Miss. Admin. Code Part 223, and

18. Compounded prescriptions except for hyperalimentation. The Division of Medicaid defines compounded prescriptions as mixtures of two or more ingredients.

C. The Division of Medicaid does not reimburse for the cost of shipping or delivering drugs.

23 Miss. Code. R. 214-1.3

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 2502, 124 Stat . 119 (2010), as amended by Pub. L. 111-152, 124 Stat. 1029 (2010); Social Security Act §§ 1927(d)(2)(7); 1935(d)(1)(2); 42 CFR §§ 423.100, 423.772, 423.906(c); 42 U.S.C. §§ 1396r-8(a), 1396r-8(d); SPA 14-011; Miss. Code Ann. § 43-13-121.

Deleted Miss. Admin. Code Part 214, Rule 1.3 B 9 and 10 to correspond with SPA 14-011 (eff. 01/01/2014), moved Miss. Admin. Code, Part 214, Chapter 1, Rule 1.3.B.16 to Miss. Admin. Code, Part 214, Chapter 1, Rule 1.3.C, eff. 07/01/2014; Revised Miss. Admin. Code Part 214, Rule 1.3.B. eff. 01/01/2013

Amended 12/1/2023