An excluded drug is a class of drugs not required to be covered by the PDP. However, some PDPs may choose to cover these drugs. Some categories of excluded drugs, not covered by the plan, will be covered by Medicaid. Excluded drug costs paid or incurred by a beneficiary may also be applied to the deductible. Medicaid will cover the following excluded drug classes;
1. Agents used for the symptomatic relief of cough and colds,
2. Prescription vitamins and mineral products, except prenatal vitamins and fluoride,
REVISED 06/01/13 – CHANGE NO. 06-13
4. Benzodiazepines, and
5. Nonprescription drugs under NC DMA General Clinical Policy A2
A non-covered drug is a drug not included in the plan’s formulary and has failed to be approved through the appeal process. These drugs are not covered by Medicaid; however, some expense for non-covered drugs may be applied to the deductible or used as an unmet medical need to reduce the PML. Refer to IV.A. above. Individuals can and should request these drugs be covered by the PDP through an appeal with the plan. Plans are required to cover these drugs during the appeal process. Individuals should contact the plan for information on how to appeal.
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.