Eligible Medications: Contraceptive pills, patches, and vaginal rings.
Prescription Limitations: Up to 12 months of refills. Follow-up required after two years.
Age Restrictions: Patients must be 18 years or older.
Documentation Requirements: Maintain patient records for 7 years; comply with HIPAA regulations.
Training Requirements: Completion of state-mandated courses for prescribing and patient counseling.
Reimbursement Details
Eligibility:
Medicaid Enrollment - Confirm Medicaid Eligibility for covered contraceptive services.
Pharmacists must be licensed in Utah and enrolled as a provider with Utah Medicaid to receive reimbursement.
Pharmacists dispensing self-administered hormonal contraceptives under a standing order are eligible for an annual consultation fee reimbursement of up to $20.
Billing Codes:
Use CPT Code 99401 (preventive counseling) with FP Modifier for family planning services. Pharmacy claims for self-administered hormonal
contraceptives must include one of the following diagnosis codes:
Z30.011 – Encounter for
initial prescription of contraceptive pills
Z30.015 – Encounter for
initial prescription of vaginal ring hormonal contraceptive
Z30.016 – Encounter for
initial prescription of transdermal patch hormonal contraceptive
Dispensing Fee:
Pharmacists can receive a dispensing fee for prescriptions billed under Medicaid when using their Medicaid-registered individual NPI.
Submission Process:
Submit claims via Utah Medicaid PRISM system.
Electronic Submission: All claims must be submitted electronically using the National Council for Prescription Drug Plan (NCPDP) Version D.0 standard.
Claims are processed in real time through the point-of-sale (POS) system.
NPI Requirement: Claims must include the prescriber’s valid National Provider Identifier (NPI). Claims with incorrect or missing NPIs will be denied or subject to recoupment.
