Will My State Cover Drugs
Excluded Under Medicare Part D?

 


The Medicare Modernization Act (MMA) excludes certain drugs from coverage under Medicare Part D, the new prescription drug program.  The excluded drugs include barbiturates (often used for seizure disorders or to relieve anxiety); benzodiazepines (including Xanax and Valium, and other drugs often used for anxiety and insomnia); drugs used for anorexia, weight loss, or weight gain; fertility drugs; drugs used for cosmetic purposes or hair growth; cough and cold medicines; prescription vitamins and mineral products; and over-the-counter drugs.

The drugs excluded under Part D are drugs that states are not required to cover under their Medicaid programs; states have the option of covering these drugs now.  The Centers for Medicare & Medicaid Services (CMS) has indicated that states have the option to continue paying for excluded drugs under their Medicaid program for people who are dually eligible for Medicare and Medicaid (dual eligibles).  CMS has cautioned states that if they cover some or all of these drugs for one category of Medicaid beneficiaries, they must cover them for all Medicaid beneficiaries.  In other words, states cannot cover some or all of these drugs for all Medicaid recipients except for the dual eligibles.

CMS has included information on its web list of the excluded drugs covered by Medicaid for each state, http://www.cms.gov/medicarereform/states/optdrugcov.asp. A summary of that information is included at the end of this Alert.

Advocacy note: Some enhanced benefit plans will cover some of the excluded drugs.  Beneficiaries who use any of these drugs and who are not eligible for Medicaid may want to consider enrolling in an enhanced benefit plan.

                      Medicare Part D Excluded Drugs Covered under Medicaid1

 

 

DRUG CATEGORY

STATE

ELIGIBILITY

Weight

Fertility

Cosmetic

Cough/Cold

Vitamins/ Minerals

OTC

Barbiturates

Benzos

Smoking Cessation

Totals

CN: Categorically Needy; MN: Medically Needy

Some 25/All 5

Some 2/All 1

Some 4/All 1

Some 16/All 19

Some 24/All 15

Some 43/All 4

Some 5/All 43

Some 8/All 42

Some 12/All 18

AL2

CN and MN

*

*

 

*

*

*

*

*

 

AK

CN

*

 

*

 

*

*

*

AZ

CN and MN

 

 

 

 

 

*

 

AR

CN and MN

*

 

 

*

*

*

*

CA2

CN and MN

 

 

*

*

*

CO

CN

 

 

 

*

CT

CN and MN

*

 

 

*

 

 

 

DE

CN

*

 

 

*

*

*

 

DC

CN and MN

*

 

 

 

*

*

 

FL

CN and MN

 

 

 

 

*

*

*

GA

CN

 

 

 

 

*

*

*

*

4

HI2

CN and MN

*

 

 

*

*

*

*

ID

CN

*

 

*

*

*

 

IL

CN and MN

 

 

*

*

IN

CN

 

 

 

*

*

IA

CN and MN

 

 

 

 

 

 

KS2

CN and MN

*

 

 

 

*

*

*

*

*

KY

CN and MN

 

 

 

 

 

3

 

LA2

CN and MN

*

*

*

 

*

*

*

ME

CN and MN

 

 

 

 

 

*

MD

CN and MN

*

 

 

*

*

 

MA

CN and MN

 

 

 

*

*

*

 

MI

CN and MN

 

 

 

 

*

*

MN2

CN and MN

*

 

*

*

*

*

MS

CN

 

 

 

*

*

*

*

*

MO

CN

 

 

 

*

*

*

*

*

 

MT

CN and MN

 

 

 

 

*

*

NE

CN and MN

*

 

 

*

*

 

NV

CN

 

 

 

NH

CN and MN

*

 

 

*

NJ

CN and MN

*

 

 

 

 

*

 

NM

CN

*

 

 

*

 

*

*

NY

CN and MN

 

 

 

*

*

5

NC

CN and MN

 

 

 

*

*

ND

CN and MN

*

 

 

 

 

*

*

OH

CN

 

 

 

6

*

OK

CN

*

 

 

*

*

*

 

OR

CN

PA

CN and MN

7

 

 

 

*

*

RI

CN and MN

*

 

 

*

*

 

SC2

CN

*

 

 

 

SD

CN

*

 

 

*

*

 

TN

CN and MN

 

 

 

 

 

 

 

 

 

TX

CN and MN

*

 

 

*

*

 

*

UT

CN and MN

 

 

 

 

*

 

VT

CN and MN

*

 

 

 

VA

CN and MN

*

 

 

*

*

WA

CN and MN

 

 

 

4

*

*

WV

CN and MN

 

 

 

*

*

*

WI

CN and MN

 

 

 

*

WY

CN

 

 

 

 

*

 

 

 

 

 

 

 

 

 

 

 

 

All

*

Some

Blank

None

 

 

 

 

 

1 Excluded Drug Coverage by State Medicaid Programs: Effective January 1, 2006, Medicaid beneficiaries who are entitled to receive Medicare benefits under Part A or Part B will no longer receive their pharmacy benefits under their State Medicaid agency, except for excluded drugs. Each State has the option to cover these drugs for their Medicaid beneficiaries who also have Medicare coverage

2 Pending CMS approval

All for full duals, except herbal products; some for other groups

No information

5  Maximum of 2 courses of treatment per year

Prior Authorization required

7  Only if prescribed for a medically acceptable indication other than obesity, anorexia, weight loss, weight gain or appetite control

Source:  CMS http://www.cms.gov/medicarereform/states/optdrugcov.asp.  Compiled 22/22/05.  Checked 22/28/05 and found changes to CMS website for Indiana, Missouri, Nebraska, North Dakota, Vermont.


Copyright Center for Medicare Advocacy, Inc. 09/10/2013