Medical assistance coverage must include coverage of a metabolic supplement if:

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1.    The metabolic supplement has been identified and agreed to be covered by the department; 2.    The metabolic supplement is part of a standard recommendation for treatment; 3.    A suitable metabolic supplement that is a covered outpatient drug is not available; 4.    The individual is under nineteen years of age; and

5.    Payment is made at a rate determined by the department.