NONPRESCRIPTION DRUGS IN THE MEDICAID PROGRAM

Section 85.20 - Definitions

NONPRESCRIPTION DRUGS IN THE MEDICAID PROGRAM

85.20 Definitions. As used in the sections under the heading "Nonprescription Drugs in the Medicaid Program" (õ 85.20 et. seq. of this Part), unless the context otherwise requires:

(a) Nonprescription drug means a drug, commonly referred to as a nonlegend or over the counter drug, which may be sold at retail by a pharmacy to the general public. Neither Federal law nor regulations of the commissioner require that such drugs be distributed or dispensed on prescription. The provisions of Education Law, section 6810(1) and the first unnumbered paragraph of section 6816 are not applicable to the sale, distribution or dispensing of such nonprescription drugs.

(b) Medical assistance program means the New York State medical assistance to the needy program (Medicaid) authorized by article 5, title 11 of the Social Services Law.

(c) Commissioner means the Commissioner of Health of the State of New York.

(d) Package size of nonprescription drug means the amount of medication required to fill a request or order for such drug. Under the medical assistance program, reimbursement for nonprescription drugs shall not be greater than the price for the available manufacturers' package or unit size which most closely corresponds to the quantity requested on such written request or order.
 

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Section 85.21 - Establishment of list of reimbursable, nonprescription drugs

85.21 Establishment of list of reimbursable, nonprescription drugs. Pursuant to section 365-a of the Social Services Law nonprescription drugs included in the therapeutic categories listed in this section may be reimbursed in the New York State Medical Assistance Program.
Product

(a) Analgesic and Antipyretic

(1) Acetaminophen
(2) Acetylsalicylic Acid

(3) Ibuprofen

(b) Antacid

(c) Antivertigo (1) Dimenhydrinate

(d) Cough and Cold

(1) Phenylephrine Hydrochloride

(2) Guaifenesin and/or Decongestant and/or Antitussive

(3) Non-Narcotic Antitussants and/or Antihistamine
(4) Antihistamine and Decongestant

(5) Nonnarcotic Antitussants and/or Upper Respiratory Combinations of Antihistamines and Decongestants

(6) Decongestant

(7) Sodium Chloride nasal drops/spray

(e) Dermatological

(1) Bacitracin

(2) Neomycin
(3) Tolnaftate

(4) Aluminum Acetate
(5) Hydrocortisone

(f) Family Planning

(1) Contraceptive

(g) Fecal Softener and Laxatives

(1) Milk of Magnesia

(2) Heavy Mineral Oil

(3) Docusate, Calcium, Potassium or Sodium

(4) Bisacodyl

(5) Bulk Laxatives

(6) Barium Enema PrepKit

(7) Senna

(h) Hematinic

(1) Ferrous Sulfate

(2) Ferrous Gluconate

(i) Insulin

(j) Vitamin/Mineral

(1) ACD with or without iron
(2) Multi-vitamin with or without iron (3) Therapeutic Vitamins with or without Minerals

(4) Prenatal Vitamins, (5) Ascorbic Acid

(6) Calcium
(7) Pyridoxine Hydrochloride

(8) Vitamin D

(9) Thiamine Hydrochloride

(10) Magnesium (11) Nicotinic Acid

(k) Basic Aluminum Carbonate Products (only for persons with diagnosis of chronic renal disease)

(l) Ocular/Oral Lubricants

(1) Lubricant Ophthalmic

(2) Sodium Chloride Ophthalmic

(3) Artificial Tears

(4) Saliva Substitute

(m) Anti-Diarrheal Product

(1) Kaolin-Pectin Combination
(2) Attapulgite Suspension

(3) Loperamide HCl

(4) Polycarbophil

(n) Antihistamines

(o) Enzyme

(1) Pancreatic Tablets

(p) Pediculicide

(q) Emetic

(1) Ipecac Syrup (r) Smoking cessation.

Effective Date: 
Wednesday, November 26, 2008
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Section 85.22 - Maximum reimbursable price and limitations on reimbursement for nonprescription drugs

85.22 Maximum reimbursable price and limitations on reimbursement for nonprescription drugs. Pursuant to section 365-a of the Social Services Law, the amount which may be reimbursed for those nonprescription drugs specified in this Part by the commissioner as a reimbursable item of medical assistance shall be the lower of:

(a) the provider's usual and customary price to the general public on the date of provision of service, but not to exceed the lower sale price, if any, in effect on that date; or

(b) the maximum reimbursable price established and maintained by the commissioner.
(c) Reimbursement shall not be available under the medical assistance program for any nonprescription drug in the following categories:

(1) A drug regularly supplied as an integral part of a medical care program activity to a Medicaid recipient by private, voluntary or public agency such as the Veterans Administration, Department of Health and Human Services, State Department of Health or other funded programs.

(2) Any drug for which there are low-cost alternatives if purchased by a Medicaid recipient, either nonprescription or prescription drugs.

(3) Any drug considered ineffective in accordance with standards developed by the Food and Drug Administration.

(4) Any drug sold after the expiration date printed on the container label.

(5) Any drug in a container whose expiration date has been altered, mutilated, destroyed, obliterated or removed by means of an affixed price sticker or other change.

Effective Date: 
Wednesday, November 26, 2008
Doc Status: 
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Section 85.23 Reserved

Effective Date: 
Wednesday, November 26, 2008