Section 140.441  Pharmacy Services Not Covered

Items excluded from coverage include the following:

a)         Drug products manufactured by drug manufacturers not meeting the rebate requirements of Section 140.440(d);

b)         Anorectic drugs or combinations including such drugs;

c)         Biologicals and drugs available without charge from the Illinois Department of Public Health or other agencies;

d)         Drugs for injection in a practitioner's office unless the cost of the drug per injection (excluding administration) exceeds $25.00;

e)         Drugs that have been classified by the Food and Drug Administration (FDA) as ineffective or unsafe in a final order;

f)         Drugs that the Food and Drug Administration has proposed in a notice of opportunity for hearing to withdraw labeled indications (pursuant to section 107(c)(3) of the Drug Amendments of 1962 (P.L. 87-781) and section 505(e) of the Federal Food, Drug and Cosmetic Act (21 USC 355(e)) and any identical, related or similar drug products (determined by the FDA in accordance with 21 CFR 310.6);

g)         Items identified as Group Care Restricted Items (see Section 140.449(b)) are not covered when provided to recipients living in licensed long-term care facilities;

h)         Sickroom Needs and Medical Equipment Items are not covered as pharmacy items.  A pharmacy that desires to provide the items must enroll as a provider of medical equipment;

i)          Miscellaneous supplies that are stocked and dispensed by some pharmacies are not covered.  These items include, but are not limited to, dental products, hair products, facial tissues, infant disposable diapers, sanitary pads, tampons, soap or other personal hygiene products, proprietary food supplements or substitutes, sugar or salt substitutes, household products, or infant formula for routine feeding; and

j)          Effective July 1, 2012, blood factor, when a patient has not had a comprehensive examination at a federally-funded Hemophilia Treatment Center during the 365 days preceding the date of service.

(Source:  Amended at 38 Ill. Reg. 12141, effective May 30, 2014)