Common use of Covered Drugs Clause in Contracts

Covered Drugs. Covered outpatient drugs would be defined to include: 1) a drug which could only be dispensed subject to a prescription and which was described in subparagraph (A)(i) or (A)(ii) of Section 1927(k)(2) of the Social Security Act (relating to drugs covered under Medicaid); 2) a biological product described in paragraph B of such subsection; 3) insulin described in subparagraph C of such section and medical supplies associated with the injection of insulin; and 4) vaccines licensed under section 351 of the Public Health Service Act. Drugs excluded from Medicaid coverage would be excluded from the definition except for smoking cessation drugs. The definition would include any use of a covered outpatient drug for a medically accepted indication. Drugs, which could be paid for under Medicare Part B, would not be covered under Part D. A plan could elect to exclude a drug, which would otherwise be covered, if the drug was excluded under the formulary and the exclusion was not successfully appealed under the new Section 1860D-3. In addition, a PDP or MA Rx or EFFS Rx plan could exclude from coverage, subject to reconsideration and appeals provisions, any drug, which would not meet Medicare’s definition of medically necessary or was not prescribed in accordance with the plan or Part D.