Utah Admin. Code R414-60-5 - Limitations
(1) Medicaid may place limitations on drugs
in accordance with 42 U.S.C.
1396r-8 or in consultation with the Drug
Utilization Review (DUR) Board. Medicaid includes these limitations in the
Pharmacy Services Provider Manual and its attachments. These limitations are
incorporated by reference in Section
R414-1-5 and may include the
following:
(a) quantity limits or cumulative
limits for a drug or drug class for a specified period;
(b) therapeutic duplication limits may be
placed on drugs within the same or similar therapeutic categories;
(c) step therapy, including documentation of
therapeutic failure with one drug before another drug may be used; or
(d) prior authorization.
(2) A pharmacy may dispense a covered
outpatient drug that requires prior authorization for up to a 72-hour supply
without obtaining prior authorization during a medical emergency.
(3) Drugs listed as non-preferred on the
Preferred Drug List (PDL) may require prior authorization as authorized by
Section 26-18-2.4.
(4) Drugs may be restricted and are
reimbursable only if dispensed by an individual pharmacy or
pharmacies.
(5) Medicaid does not
cover drugs not eligible for federal medical assistance percentages
funds.
(6) Medicaid does not cover
outpatient drugs included in the Medicare Prescription Drug Benefit-Part D for
full-benefit dual eligible members.
(7) Medicaid does not cover drugs provided to
a member during an inpatient hospital stay, neither as an outpatient pharmacy
benefit nor separately payable from the Medicaid payment for the inpatient
hospital services.
(8) Medicaid
covers prescription cough and cold preparations meeting the definition of a
covered outpatient drug.
(9)
Medicaid pays for no more than a one-month supply of a covered outpatient drug
for each dispensing, except for the following:
(a) Medicaid may cover medications on the
Utah Medicaid Three-Month Supply Medication List, attachment to the Pharmacy
Services Provider Manual, for up to a three-month supply per
dispensing;
(b) Medicaid may cover
prenatal vitamins for a pregnant woman, multiple vitamins with or without
fluoride for a child who is zero through five years of age, and fluoride
supplements for up to a three-month supply per dispensing;
(c) Medicaid may cover contraceptives for up
to a three-month supply per dispensing; and
(d) Medicaid may cover long-acting injectable
antipsychotic drugs in accordance with Section
R414-60-12 for up to a
three-month supply per dispensing.
(10) Medicaid pays for a prescription refill
only if 80% of the previous prescription has been exhausted, with the exception
of controlled substances. Medicaid pays for a prescription refill for
controlled substances after 85% of the previous prescription has been
exhausted.
(11) Medicaid does not
cover the following drugs:
(a) drugs for
weight loss;
(b) drugs to promote
fertility;
(c) drugs for the
treatment of sexual dysfunction;
(d) drugs for cosmetic purposes;
(e) vitamins; except for prenatal vitamins
for a pregnant woman, vitamin drops for a child who is zero through five years
of age, and fluoride supplements;
(f) over-the-counter drugs (OTC) not included
on the Utah Medicaid PDL and Resources attachment to the Pharmacy Services
Provider Manual;
(g) drugs for
which the manufacturer requires, as a condition of sale, that associated tests
and monitoring services are purchased exclusively from the manufacturer or its
designee;
(h) drugs given by a
hospital to a patient at discharge;
(i) breast milk, breast milk substitutes,
baby food, or medical foods. Prescription metabolic products for congenital
errors of metabolism are covered through the Durable Medical Equipment benefit;
and
(j) drugs available only
through single-source distribution programs, unless the distributor is enrolled
with Medicaid as a pharmacy provider.
(12) Claims for opioids used for the
treatment of non-cancer pain are subject to the following limitations or
restrictions set forth by the Division of Integrated Healthcare:
(a) initial fill limits;
(b) monthly limits;
(c) quantity limits;
(d) additional limits for a child or pregnant
woman;
(e) morphine milligram
equivalents (MME) and cumulative morphine equivalents daily (MED)
limits;
(f) concurrent use of
opioids with high-risk drugs as defined by DMHF; or
(g) concurrent use of opioid medications in
members who also receive medication-assisted treatment (MAT) for opioid use
disorder.
(13)
Antipsychotic medications prescribed to a Medicaid member who is 19 years of
age or younger are limited as follows:
(a) no
use of multiple antipsychotic drugs;
(b) no off-label use;
(c) no use outside established age
guidelines; and
(d) no doses higher
than FDA recommendations.
(14) Exceptions may be granted as appropriate
through the prior authorization process.
(15) Attention-deficit/hyperactivity disorder
(ADHD) stimulant medications are subject to the following limitations or
restrictions set forth by DMHF for Medicaid members:
(a) age limits;
(b) monthly limits;
(c) quantity limits;
(d) cross-class limitations for concurrent
use of an amphetamine class with methylphenidate class in children less than 18
years of age; or
(e) the use of no
more than two ADHD stimulants by a member of any age.
(16) Medicaid evaluates exceptions to ADHD
stimulant policy for medical necessity on a case-by-case basis.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
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