R414-60-5. Limitations

  (1) Limitations may be placed on drugs in accordance with 42 U.S.C. 1396r-8 or in consultation with the Drug Utilization Review (DUR) Board. Limitations are included in the Pharmacy Services Provider Manual and attachments, incorporated by reference in Section R414-1-5, and may include:

  (a) Quantity limits or cumulative limits for a drug or drug class for a specified period of time;

  (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 covered outpatient drug that requires prior authorization may be dispensed 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 may require prior authorization as authorized by Section 26-18-2.4.

  (4) Drugs may be restricted and are reimbursable only when 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 beneficiaries.

  (7) Drugs provided to clients during inpatient hospital stays are not covered as an outpatient pharmacy benefit nor separately payable from the Medicaid payment for the inpatient hospital services.

  (8) Medicaid covers only the following prescription cough and cold preparations meeting the definition of a covered outpatient drug:

  (a) Guaifenesin with Dextromethorphan (DM) 600mg/30mg tablets;

  (b) Guaifenesin with Hydrocodone 100mg/5mL liquid;

  (c) Promethazine with Codeine liquid;

  (d) Guaifenesin with Codeine 100mg/10mg/5mL liquid;

  (e) Carbinoxamine with Pseudoephedrine 1mg/15mg/5mL liquid; and

  (f) Carbinoxamine/Pseudoephedrine/DM 15mg/1mg/4mg/5mL liquid.

  (9) Medicaid will pay for no more than a one-month supply of a covered outpatient drug per dispensing, except for the following:

  (a) Medications included on the Utah Medicaid Three-Month Supply Medication List attachment to the Pharmacy Services Provider Manual may be covered for up to a three-month supply per dispensing. Medicaid clients eligible for Primary Care Network services under Rule R414-100 are not eligible to receive more than a one-month supply per dispensing.

  (b) Prenatal vitamins for pregnant women, multiple vitamins with or without fluoride for children through five years of age, and fluoride supplements may be covered for up to a 90-day supply per dispensing.

  (c) Medicaid may cover contraceptives for up to a three-month supply per dispensing.

  (d) Medicaid may cover long-acting injectable antipsychotic drugs in accordance with Section R414-60-12 for up to a 90-day supply per dispensing.

  (10) Medicaid will pay for a prescription refill only when 80% of the previous prescription has been exhausted, with the exception of narcotic analgesics. Medicaid will pay for a prescription refill for narcotic analgesics after 100% of the previous prescription has been exhausted.

  (11) Medicaid does not cover the following drugs:

  (a) Drugs not eligible for Federal Medical Assistance Percentages funds;

  (b) Drugs for anorexia, weight loss or weight gain;

  (c) Drugs to promote fertility;

  (d) Drugs for the treatment of sexual or erectile dysfunction;

  (e) Drugs for cosmetic purposes or hair growth;

  (f) Vitamins; except for prenatal vitamins for pregnant women, vitamin drops for children through five years of age, and fluoride supplements;

  (g) Over-the-counter drugs not included in the Utah Medicaid Over-the-Counter Drug List attachment to the Pharmacy Services Provider Manual;

  (h) 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;

  (i) Drugs given by a hospital to a patient at discharge;

  (j) Breast milk, breast milk substitutes, baby food, or medical foods, except for prescription metabolic products for congenital errors of metabolism;

  (k) Drugs available only through single-source distribution programs, unless the distributor is enrolled with Medicaid as a pharmacy provider.

  (12) Medicaid may only cover hemophilia clotting factor when it is dispensed by a single-contracted provider in accordance with the Utah Medicaid State Plan.