Non-covered items shall include:

1. (a) Experimental or investigational drugs not approved by the FDA;
2. (b) Drugs listed by the FDA as being DESI drugs or IRS drugs;
3. (c) Legend and non-legend drugs that are not part of a medical treatment for a specific illness, injury, or disease;

4. (d) Non-legend drugs when:

   1. (1) A legend drug effecting the same health outcome is available and:

      1. a. Is more clinically effective; or
      2. b. Is therapeutically equivalent and more cost effective; or

   2. (2) The non-legend drug is being used to primarily treat discomfort or to maintain comfort, including, but not limited to:

      1. a. Antidiarrheals;
      2. b. Antiflatulants;
      3. c. Nasal decongestants;
      4. d. Eye and ear preparations; and
      5. e. Topical antipruitics;

5. (e) Non-legend drugs and supplies, which are household and medicine chest items, including, but not limited to:

   1. (1) Band-aids;
   2. (2) Corn plasters;
   3. (3) Contact lens products;
   4. (4) Cough drops and lozenges;
   5. (5) Mouthwash;
   6. (6) Nursery supplies;
   7. (7) Nutritional supplements when not needed to sustain life;
   8. (8) Odor barrier products;
   9. (9) Personal hygiene items;
   10. (10) Sunscreen;
   11. (11) Soaps and cleansers;
   12. (12) Acne products;
   13. (13) Products to mitigate seborrheic dermatitis; and
   14. (14) Fluoride preparations;
6. (f) Legend and non-legend drugs used for the symptomatic relief of cough and colds, pursuant to Section 1396r-8(d)(2)(D) of the Social Security Act;
7. (g) Legend and non-legend drugs used for cosmetic purposes or hair growth, pursuant to Section 1396r-8(d)(2)(C) of the Social Security Act;
8. (h) Legend and non-legend drugs which enhance or promote fertility or procreation, or for which the labeled use is ovulation stimulation, pursuant to Section 1396r-8(d)(2)(B) of the Social Security Act;
9. (i) Legend and non-legend drugs without a prescription from a licensed practitioner;
10. (j) Legend and non-legend drugs when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the FDA, pursuant to Section 1396r-8(d)(2)(k); and
11. (k) Items which are free to the general public.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93; amd by #5874, eff 8-1-94; ss by #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02 New. #7805, eff 12-21-02; ss by #8372, eff 8-1-05; ss by 8628, eff 5-6-06; ss by #9831, eff 12-21-10; ss by #12529, eff 5-22-18