Section 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(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: (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;(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: (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.Utah Admin. Code R414-60-5
Amended by Utah State Bulletin Number 2016-24, effective 12/1/2016Amended by Utah State Bulletin Number 2017-8, effective 4/1/2017Amended by Utah State Bulletin Number 2018-10, effective 5/1/2018Amended by Utah State Bulletin Number 2020-02, effective 1/1/2020Amended by Utah State Bulletin Number 2020-13, effective 6/19/2020Amended by Utah State Bulletin Number 2020-23, effective 11/19/2020Amended by Utah State Bulletin Number 2021-07, effective 3/26/2021Amended by Utah State Bulletin Number 2021-11, effective 5/12/2021Amended by Utah State Bulletin Number 2023-20, effective 10/11/2023