Utah Admin. Code R414-60-4 - Program Coverage

(1) Covered outpatient drugs eligible for federal medical assistance percentages funds are included in the pharmacy benefit; however, covered outpatient drugs may be subject to limitations and restrictions.

(2) In accordance with Subsection 58-17b-606(4), if a multi-source A-rated legend drug is available in the generic form, Medicaid reimburses only for the generic form of the drug unless:

(a) reimbursing for the non-generic brand-name legend drug will result in a financial benefit to the state;

(b) the treating physician demonstrates a medical necessity for dispensing the non-generic, brand-name legend drug; or

(c) the generic form of the drug is unavailable in the marketplace as defined in the Utah Medicaid Pharmacy Services Provider Manual.

(3) 42 U.S.C 1396b(i)(23) requires Medicaid prescriptions not executed electronically to be written on tamper-resistant prescription forms as follows:

(a) tamper-resistant prescription forms must include each of the following:

(i) one or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form;

(ii) one or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber; and

(iii) one or more industry-recognized features designed to prevent the use of counterfeit prescription forms.

(b) Documentation by the pharmacy of verbal confirmation of a prescription not written on a tamper -resistant prescription form by the prescriber or the prescriber's agent satisfies the tamper-resistant requirement. Documentation of the verbal confirmation must include the date, time, and name of the individual who verified the validity of the prescription.

(c) A pharmacy must maintain documentation that a Medicaid member or authorized representative has received a prescription for a covered outpatient drug. The documentation must clearly identify the covered outpatient drug and the date it was received.

(i) The Division of Integrated Healthcare shall waive the proof of delivery requirement for Non-Controlled Schedule 2 prescriptions.

(ii) In accordance with Subsection R414-60-4(3)(c), the proof of delivery requirement remains for Controlled Schedule 2 (CII) medications that includes a signature or other documentation. The pharmacy shall document member receipt as stated in Subsection R414-60-4(3)(c).

(d) Claims for covered outpatient drugs not dispensed to a Medicaid member or the member's authorized representative within 14 days must be reversed and any payment from Medicaid must be returned.

Notes

Utah Admin. Code R414-60-4

Amended by Utah State Bulletin Number 2016-24, effective 12/1/2016 Amended by Utah State Bulletin Number 2020-02, effective 1/1/2020 Amended by Utah State Bulletin Number 2020-23, effective 11/23/2020 Amended by Utah State Bulletin Number 2021-02, effective 1/12/2021 Amended by Utah State Bulletin Number 2023-20, effective 10/11/2023