Drug coverage policies are based on medical necessity considerations subject to applicable benefits. These documents assist with medical necessity coverage decisions, may include state-specific guidance regarding coverage and do not constitute medical advice. Benefit determination is based on the applicable contract language and/or state requirements.
These policies are not a guarantee of coverage. Contract language or state requirements will prevail when there are conflicts with any medication coverage policy. In all cases, Medicaid contracts or Centers for Medicare & Medicaid Services requirements supersede policy criteria.