1. (1) Medicaid may place limitations on drugs in accordance with 42 U.S.C. 1396r-8 or in consultation with the Drug Utilization Review Board. Medicaid includes these limitations in the Pharmacy Services Provider Manual and attachments. These limitations are incorporated by reference in Section R414-1-5 and may include:

   1. (a) quantity limits or cumulative limits for a drug or drug class for a specified period;
   2. (b) therapeutic duplication limits, which may be placed on drugs within the same or similar therapeutic categories;
   3. (c) step therapy, including documentation of therapeutic failure with one drug before another drug may be used; or
   4. (d) prior authorization.
2. (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. (3) A drug listed as non-preferred on the Preferred Drug List (PDL) may require prior authorization as authorized by Section 26B-3-105.
4. (4) A drug may be restricted and is reimbursable only if dispensed by an individual pharmacy or pharmacies.
5. (5) Medicaid does not cover any drug not eligible for federal medical assistance percentages funds.
6. (6) Medicaid does not cover any outpatient drug included in the Medicare Prescription Drug Benefit-Part D for any full-benefit dual eligible member.
7. (7) Medicaid does not cover any drug 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. (8) Medicaid covers prescription cough and cold preparations meeting the definition of a covered outpatient drug.

9. (9) Medicaid pays for no more than a one-month supply of a covered outpatient drug for each dispensing, except that:

   1. (a) Medicaid may cover a medication on the Utah Medicaid Three-Month Supply Medication List, attachment to the Pharmacy Services Provider Manual, for up to a three-month supply for each dispensing;
   2. (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 for each dispensing;
   3. (c) Medicaid may cover contraceptives for up to a three-month supply for each dispensing; and
   4. (d) Medicaid may cover a long-acting injectable antipsychotic drug in accordance with Section R414-60-12 for up to a three-month supply for each dispensing.
10. (10) Medicaid pays for a prescription refill only if 80% of the previous prescription has been exhausted, except for a controlled substance. Medicaid pays for a prescription refill for a controlled substance after 85% of the previous prescription has been exhausted.
11. (11) Medicaid covers treatments for fertility preservation and in vitro fertilization, only as described in the Utah Medicaid Provider Manual, for individuals who receive medical treatment that includes surgery, radiation, chemotherapy, or another medical intervention that poses the risk of sterility or leads to iatrogenic infertility.

12. (12) Medicaid does not cover:

    1. (a) a drug for weight loss, except for specific indications;
    2. (b) a drug for the treatment of sexual dysfunction;
    3. (c) a drug for cosmetic purposes;
    4. (d) 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;
    5. (e) an over-the-counter drug (OTC) not included on the Utah Medicaid PDL and Resources attachment to the Pharmacy Services Provider Manual;
    6. (f) a drug 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;
    7. (g) a drug given by a hospital to a patient at discharge;

    8. (h) 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

       1. (i) a drug available only through a single-source distribution program, unless the distributor is enrolled with Medicaid as a pharmacy provider.

13. (13) A claim for opioids used for the treatment of non-cancer pain is subject to the following limitations or restrictions set forth by the Division of Integrated Healthcare (DIH):

    1. (a) initial fill limits;
    2. (b) monthly limits;
    3. (c) quantity limits;
    4. (d) additional limits for a child or pregnant woman;
    5. (e) morphine milligram equivalents (MME) and cumulative morphine equivalents daily (MED) limits;
    6. (f) concurrent use of opioids with high-risk drugs as defined by DIH; or
    7. (g) concurrent use of opioid medications in members who also receive medication-assisted treatment (MAT) for opioid use disorder.

14. (14) An antipsychotic medication prescribed to a Medicaid member who is 19 years of age or younger is limited as follows:

    1. (a) no use of multiple antipsychotic drugs;
    2. (b) no off-label use;
    3. (c) no use outside established age guidelines; and
    4. (d) no doses higher than FDA recommendations.
15. (15) An exception may be granted as appropriate through the prior authorization process.

16. (16) An attention-deficit/hyperactivity disorder (ADHD) stimulant medication is subject to the following limitations or restrictions set forth by DIH for Medicaid members:

    1. (a) age limits;
    2. (b) monthly limits;
    3. (c) quantity limits;
    4. (d) cross-class limitations for concurrent use of an amphetamine class with methylphenidate class in children less than 18 years of age; or
    5. (e) the use of no more than two ADHD stimulants by a member of any age.
17. (17) Medicaid evaluates exceptions to ADHD stimulant policy for medical necessity on a case-by-case basis.
18. (18) The "dispense as written" DAW-1 code may override the non-preferred prior authorization for antipsychotic medications if the prescriber writes "dispense as written" on a prescription.

KEY: Medicaid

Date of Last Change: January 20, 2026

Notice of Continuation: March 11, 2022

Authorizing, and Implemented or Interpreted Law: 26B-1-213; 26B-3-108