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Model Application Template for the State Children's Health Insurance Program

Effective Date: August 24, 2001

Approval Date: 28 are medically necessary for the administration of legend drugs used for the delivery of respiratory or inhalation therapy; • Syringes and needles for the administration of medication covered under this chapter; • Urine and blood testing items for a diabetic, except for glucometers, which are covered as medical equipment; • Family planning items; and • Smoking cessation drugs.

Non-covered services include: • Non-legend prescription drugs and over-the-counter items and medical supplies except for those specifically listed above; • Medical supplies or delivery charges; • Legend oral vitamins except for legend vitamins prescribed for the prenatal care of pregnant women. • Items prescribed for weight control or appetite depressants;

• Agents to promote fertility or treat impotence; • Agents used for cosmetic purposes; • Hair growth products; • Items or drugs manufactured by a firm that has not signed a rebate agreement with the CMS; • Items which exceed a 34-day supply, except for family planning items and prenatal vitamins; • Services, procedures, or drugs which are considered experimental; • Drugs and biologicals which the federal government has determined to be less than effective. Prescription drug services are included as PCCM services, with the exception of family planning drugs and items. Azidothymidine is available only for persons diagnosed with HIV. Clozaril and growth hormones are prior authorized.

6.2.7. X Over-the-counter medications (Section 2110(a)(7))

See 6.2.6.

6.2.8. X Laboratory and radiological services (Section 2110(a)(8))

Covered under 6.2.1, 6.2.2, 6.2.3, 6.2.4, 6.2.5 for diagnostic and treatment purposes. Coverage includes materials and services of technicians. Laboratory services are not included as PCCM services. There are no limitations on services provided.