C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-80, subsec. 144-101-II-80.05

Current through 2024-44, October 30, 2024

Subsection 144-101-II-80.05 - COVERED SERVICES

80.05-1Drug Benefits

Reimbursement is available for the following drugs when medically necessary.

A.Legend drugs. All legend drugs found on the MaineCare program State drug file, except those drugs set forth in Section 80.05-3, which must meet the requirements of prior authorization, and those drugs set forth in Section 80.05-4, which are covered for certain diagnoses only as set forth in that Section. In addition, those legend drugs described as a non-covered service in Section 80.06 are not reimbursable.

B.Over-the-Counter drugs. Some over-the-counter drugs and supplies are covered when filled pursuant to a prescription. Over-the-counter drugs will be eligible for reimbursement, by prescription only, if such coverage is efficacious, safe, has a lower net cost, the drug has an NDC, and coverage is recommended by the Drug Utilization Review Committee and approved by the Department. A list of covered over-the-counter drugs will be posted and updated on the Department's designated website.

C.Medicare Part D Excluded Drugs

The Department will post a complete list on its designated website of Medicare Part D Excluded Drugs that are covered drugs under this Section to the extent that they are covered for MaineCare non-dual eligible members.

80.05-2Compound Prescriptions

Reimbursement may be made for a compound prescription when the Department determines that the compound prescription contains at least one ingredient that is a legend drug, present in a therapeutic quantity, and obtainable in effective strength only by prescription.

A compound prescription, which contains a laxative, stool softener, vitamin, antacid or cough and cold preparation and is prescribed solely to circumvent these MaineCare reimbursement limitations, is not covered. Reimbursement for compound drugs must not include the cost of DESI (less than effective) drugs. The primary ingredient contained in a compound prescription must be covered under a rebate agreement with the MaineCare program and have a valid NDC in the State's drug file.

80.05-3Drugs and Products Covered for Certain Conditions/Procedures Only

Reimbursement for Methamphetamine, methylphenidate, dexmethylphenidate, and dextroamphetamine for attention deficit disorders or narcolepsy will be made only for the conditions described and only when the prescriber has written the diagnosis on the prescription.

Reimbursement for formula as a medical food product will available for a member with special nutrient needs when the prescription includes a written diagnosis.

For a member living in a nursing facility or an ICF-IID the diagnosis must be noted in the member's chart.

80.05-4Drugs Obtained Through the Department's Mail Order Pharmacy Providers

Members are not required to obtain drugs through mail order. Members may voluntarily choose to obtain drugs through mail order. All prior authorization requirements apply to drugs obtained through mail order pharmacy providers. There is no member co-payment for drugs obtained through a mail order pharmacy provider. When refilling a prescription through a mail order pharmacy provider, refills may be provided only by a member's request; mail order pharmacy providers may not automatically refill prescriptions for members.

Providers of mail order pharmacy services must be enrolled as a Mail Order Pharmacy Provider. The Department or mail order pharmacy providers will provide members and providers with instructions for submitting a prescription by mail order.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-80, subsec. 144-101-II-80.05