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), when a multi-source A-rated legend drug is available in the generic form, Medicaid will only reimburse 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; or

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

  (3) Prescriptions that are not executed electronically must be written on tamper-resistant prescription forms. Tamper-resistant prescription forms must include all of the following:

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

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

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

  (d) 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.

  (e) Pharmacies must maintain documentation of receipt of a prescription by a Medicaid client or the client's authorized representative. The documentation must clearly identify the covered outpatient drug received by the client, the date the covered outpatient drug was received, and who received the covered outpatient drug.

  (f) Claims for covered outpatient drugs not dispensed to a Medicaid client or the client's authorized representative within 10 days must be reversed and any payment from Medicaid must be returned.