Utah Administrative Code
Topic - Health
Title R414 - Integrated Healthcare
Rule R414-60 - Medicaid Policy for Pharmacy Program
Section 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 Utah 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) Dispensing fees are outlined in Attachment 4.19-B of the Utah Medicaid State Plan. Medicaid pays the lesser of the assigned dispensing fee or the submitted dispensing fee.

(7) Medicaid pays a pharmacy only one dispensing fee every 24 days for each covered outpatient drug.

(8) 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. Medicaid pays the lesser of the allowed or 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 the wholesale acquisition cost with no dispensing fee 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/medicaid/stplan/lookup/CoverageLookup.php.