Utah Admin. Code R414-60-7 - Reimbursement
(1) A pharmacy may not submit a charge to
Medicaid that exceeds the pharmacy's usual and customary charge.
(2) Covered outpatient drugs are reimbursed
as outlined in Attachment 4.19-B of the Medicaid State Plan.
(3) A pharmacy that participates in the 340B
program and uses medications obtained through the 340B program to bill Medicaid
must submit the acquisition cost of the medication on the claim.
(4) A pharmacy that participates in the
federal supply schedule and uses medications obtained through the schedule to
bill Medicaid must submit the acquisition cost of the medication on the claim
unless the claim is reimbursed as a bundled charge or all -inclusive
rate.
(5) A pharmacy that obtains
and uses medications at a nominal price must submit the acquisition cost of the
medication on the claim.
(6)
(a) Dispensing fees are outlined in
Attachment 4.19-B of the Medicaid State Plan.
(b) Medicaid pays the lesser of:
(i) the assigned dispensing fee; or
(ii) the submitted dispensing fee.
(7)
(a) Medicaid pays a pharmacy only one
dispensing fee every 24 days for each covered outpatient drug.
(b) In the event the Medicaid point of sale
system experiences a system interruption that results in extensive downtime and
increased administrative workload for pharmacy providers, the Medicaid division
director may waive the 24-day limit on dispensing fees.
(8)
(a)
Medicaid pays a provider that immunizes a Medicaid member who is 19 years of
age or older for the cost of the immunization plus a dispensing fee.
(b) Medicaid pays the lesser of:
(i) the allowed charges; or
(ii) the submitted charges.
(9) A provider that
immunizes a Medicaid member who is 18 years of age or younger may only be
eligible for a dispensing fee with no reimbursement for the immunization.
Immunizations for Medicaid members who are 18 years of age or younger must be
obtained through the Vaccines for Children program.
(10) Diabetic supplies listed on the Utah
Medicaid PDL are reimbursed at the lesser of:
(a) the wholesale acquisition cost with no
dispensing fee;
(b) or the billed
charges.
(11) Pursuant to
Section 58-17b-805, a dispensing medical
practitioner may prescribe and dispense medication directly to a patient if
providing outpatient cancer therapy. Details of reimbursement are found on the
Medicaid website at
http://health.utah.gov/stplan/lookup/CoverageLookup.php.
Notes
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