Filing an appeal with Medicaid to cover over the counter items

            We recently were successful in completing the process to have many of my son’s over-the-counter medications covered by Medicaid.  It took a great deal of persistence not only on my part, but also his physicians’.  After three long months, our hard work paid off.  It is such a relief to have basic necessities (aquaphor healing, eucerin ointment, puralube eye ointment, and aquaphor baby wash) covered by Medicaid.  Be prepared for a great deal of effort, but hopefully these steps will help get you started on the right path:

1)      Read your Medicaid booklet carefully.  In North Carolina, it specifies that Medicaid must cover any medication that cures/ameliorates (makes better) a medical condition.  Lotions, etc. can ameliorate Ichthyosis.

2)      Speak to your/your child’s physician about the need for items to be covered.  Our physician was amazed at the vast quantities of these items we were purchasing each month.  Ask if they would be willing to contact Medicaid to file an appeal and send pertinent medical records.  In addition, my son’s physician was asked by Medicaid to write a letter explaining what medications, what quantity, and why they are needed (what do they prevent from happening?).

3)      Call Medicaid and request a TAR form for an appeal.  Explain why you/your child need(s) these items.  When I made this first phone call, I was on the phone for upwards of four hours before I finally reached the person I needed to speak with.

4)      After sending in the completed form, I called my contact in the pharmacy division weekly to get an update.  It really helps if you have someone on your side there when the case is brought the physician in charge of making the decision.  They also understood how important it was that my son receive these medications.

5)      As you near the completion process, find a sympathetic pharmacy.  We use a small, independent pharmacy that was willing to stay on the phone all day—literally—with Medicaid.  Because some of the over the counters do not have NDC numbers, it made the process difficult. 

6)      Make sure when the process is complete to thank everyone who helped you along the way. 

7)      Make sure to read your paperwork carefully where you can request the medications again in a timely fashion with another form (sometimes it is in 6 months, sometimes in 1 year). 

I hope that this is helpful.  If I can be of further assistance in this process, please email me at: info@ichthyosis.us