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

Effective Date:

Approval Date: 32 • Covered, medically necessary surgical services are limited to services that directly relate to the delivery of the unborn child enrolled in the program until birth. • Coverage for the CHIP Perinatal newborn is the same as coverage for CHIP clients.

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) Covered, unlimited medically necessary clinic services (including health center services) and other ambulatory health care services, and limitations and exclusions to these services are described under outpatient services.

CHIP Perinatal Program: • Covered, medically necessary clinic services are limited to prenatal and postpartum care and/or the delivery of the covered unborn child until birth. • Ultrasound of the pregnant uterus is a covered benefit of the CHIP Perinatal Program when medically indicated. Ultrasound may be indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age conformation. • Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT) and Ultrasonic Guidance for Amniocentesis, Cordocentrsis, and FIUT are covered benefits of the CHIP Perinatal Program with an appropriate diagnosis. • Coverage for the CHIP Perinatal newborn is the same as coverage for CHIP clients.

6.2.6.

Prescription drugs (Section 2110(a)(6)) Open formulary based on the Texas Medicaid Program open formulary. Covered, unlimited medically necessary prescription drugs include non-experimental, FDA-approved physician- prescribed drugs that are prescribed for the medical treatment of illness or injuries.

Exclusions include: contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care; and, medications for weight loss or gain.

The state will require prior authorization for selected drugs. The state will also implement a preferred drug list (with provisions for medically necessary exceptions) and may establish a four- prescription limit on brand name drugs and a thirty-four day supply limit, if determined to be cost effective. Medically necessary exceptions will also apply to both of these limits.