Drug Coverage

NOTE: All supplies are to be submitted to the Hawaii Medicaid Fiscal Agent for processing and reimbursement. Supplies can include DME, Diabetic, Medical, Prosthetic, Orthotic, etc. Supplies must be billed by HCPCS codes and not NDC numbers. For questions, please contact the Hawaii Medicaid Fiscal Agent at 808-952-5570 or 800-235-4378.
 

Updated 8/27/2009

Hawaii Medicaid FFS Program Drug Coverage

The information included in this document details coverage by identifying products that are not covered, and products that may be subject to coverage restrictions (plan limits, clinical criteria). The products not listed are to be considered as covered.The intent of this document is to provide a high level overview of Hawaii Medicaid drug coverage, and is based upon fee for service plan coverage.

Drug coverage is subject to hard coding, plan limitations, recipient eligibility, and recipient plan coverage.
 

Not Covered Medications

  • DESI drugs
  • Rogaine/Minoxidil/Propecia/Renova/Cosmetic Agents
  • Fertility agents
  • Non-rebate drugs
  • Diabetic supplies and glucometers are not covered at point-of-sale. Hawaii Medicaid Fiscal Agent must be billed.
  • Enteral nutrition is not covered POS.
  • Anti-Impotency agents
  • Cholestyramine (Questran) pre-measured packets are not covered. Bulk powder is covered. 
     

Not Covered Medications

  • Anti-leprotic medications (e.g., Dapsone, Lamprene) for leprosy are not covered (ICD9 required on the claim)
  • Cholestyramine (Questran) pre-measured packets are not covered. Bulk powder is covered.
  • DESI drugs
  • Drugs covered by Medicare for Medicare eligible Recipients. A diagnosis code is required on claims for immunosupressants and oral anti-cancer medications for recipients with Medicare coverage.
  • Drugs used to treat pulmonary tuberculosis are not covered (rifampin, ethambutol, pyrazinamide). A diagnosis code is required on claims for these medications.
  • Diabetic supplies and glucometers are not covered at point-of-sale (POS). Hawaii Medicaid Fiscal Agent in Honolulu must be billed.
  • Enteral nutrition is not covered at POS. Must be billed on paper if from a home infusion pharmacy. Non-home infusion pharmacies must submit claims for enteral nutrition to Hawaii Medicaid Fiscal Agent.
  • Fertility agents
  • Non-rebate drugs
  • Rogaine/Minoxidil/Propecia/Renova/Cosmetic and agents for cosmetic purposes (Retin-A and acne medications are covered when used for acne/dermatoses.)
  • Smoking cessation products with the exception of Zyban
  • Vaccines for travel (Japanese encephalitis, typhoid, yellow fever, cholera)
  • Yohimbine HCl and Yohimbine-combination drugs
     

Prior Authorized Medications

  • See drugs and drug classes requiring prior authorization in Prior Authorization Criteria section.