## Facts

- Medicaid-eligible individuals with AIDS or HIV-related conditions sought Missouri Medicaid coverage for AZT (Retrovir), an FDA-approved antiretroviral drug for AIDS treatment.
- Missouri Medicaid limited AZT coverage to a narrow subset of patients under state criteria derived from the FDA-approved labeling and denied coverage to other eligible recipients whose physicians prescribed AZT as medically necessary.
- A named plaintiff later became eligible under Missouri’s amended rules, but additional plaintiffs intervened and the case continued as a class action on behalf of similarly situated Medicaid recipients.
- The district court found AZT was medically necessary for class members excluded by Missouri’s criteria, granted summary judgment for the class, and enjoined Missouri officials from denying AZT coverage to class members for whom it was medically necessary.
- Missouri officials appealed, disputing the Medicaid Act interpretation and whether the asserted Medicaid rights were enforceable under 42 U.S.C. § 1983.

## Issues

1. Whether Missouri’s restrictive AZT coverage rules were consistent with federal Medicaid requirements once the state elected to cover prescription drugs.
2. Whether federal Medicaid provisions at issue created rights enforceable by Medicaid recipients under 42 U.S.C. § 1983.
3. Whether Missouri could use FDA labeling and utilization-control criteria to categorically deny AZT to otherwise eligible recipients despite physician determinations of medical necessity.

## Decision

- The Eighth Circuit affirmed the grant of summary judgment for the plaintiff class.
- The court held Missouri’s AZT restrictions conflicted with federal Medicaid requirements by denying medically necessary drug coverage within a covered service category.
- The court held the relevant Medicaid provisions conferred enforceable rights on eligible recipients, permitting suit under § 1983.
- The injunction barring Missouri officials from denying AZT to class members for whom it was medically necessary remained in effect.

## Legal Principles

- When a state participates in Medicaid, it must administer its plan in compliance with federal statutory requirements governing covered services.
- Once a state elects to cover a category of benefits (including prescription drugs), it may not apply restrictions that effectively withhold medically necessary treatment from eligible recipients.
- Medicaid recipients may enforce specific, beneficiary-directed federal Medicaid requirements through 42 U.S.C. § 1983 when the provisions impose substantive obligations rather than general policy goals.
- State utilization controls must remain within federal limits; cost-control measures cannot justify categorical denials that conflict with medical necessity and the plan’s obligation to furnish adequate coverage.
- FDA-approved labeling may inform clinical and administrative decision-making but does not, by itself, authorize a state to treat the label as a fixed ceiling that overrides coverage of medically necessary treatment for eligible recipients.

## Conclusion

The court upheld an injunction requiring Missouri Medicaid to cover AZT for eligible AIDS patients when prescribed as medically necessary, and it confirmed that recipients could use § 1983 to challenge state Medicaid policies that deny federally required benefits through overly restrictive coverage criteria.


Weaver v. Reagen, 886 F.2d 194 (8th Cir. 1989)