Common use of Covered Drugs Clause in Contracts

Covered Drugs. The New Section 1860 D would define covered drugs as drugs, biological products, and insulin (including syringes, and necessary medical supplies associated with the administration of insulin, as defined by the Administrator) which are covered under Medicaid and vaccines licensed under Section 351 of the Public Health Service Act. Coverage would be extended to any use of a covered drug for a medically accepted indication. The term would not include drugs or classes of drugs, or their medical uses, which could be excluded from coverage under Medicaid, except for smoking cessation agents. The term would not include drugs currently covered under Medicare Part A or Medicare Part B to the extent payment is available under those Parts. A drug prescribed for an individual, which would ordinarily be a covered drug, would not be covered if a plan’s formulary excluded the drug and the exclusion was not successfully resolved. Further, a Medicare Prescription Drug plan or a MedicareAdvantage plan could exclude drugs which did not meet Medicare’s definition of “reasonable and necessary” under Section 1862(a) of the Act or which were not prescribed in accordance with the requirements of the plan or Part D. New Section 1860D-1 would specify that the program would provide coverage for all therapeutic categories and classes of covered drugs (though not necessarily for all drugs within such categories and classes).