Restrictions
The Medicaid Restriction Program Can be of Help in Managing Addictive Behaviors
The Restriction Program can assist in managing appropriate access to medical resources by assigning Medicaid members to one Primary Care Provider (PCP) and one primary pharmacy. Medicaid members enrolled the Restriction Program must use their assigned PCP, specialty providers approved by the PCP and assigned pharmacy in order for claims to be paid by Medicaid.
Referrals for possible enrollment in the Restriction Program may be submitted at email medicaidrestriction@utah.gov or 801-538-9045.
Medicaid members referred to the Restriction Program for possible misuse of Medicaid resources will be reviewed for meeting or exceeding the following Restriction criteria during their most recent 12 months of Medicaid eligibility:
- ≥ 4 providers
- ≥ 4 pharmacies for abuse potential prescriptions
- ≥ 6 abuse potential medications in a two month period
- ≥ 3 providers prescribing abuse potential medications in a two month period
- ≥ 5 non emergent ED visits
- concurrent prescriptions for abuse potential medications from different prescribers
Member’s diagnoses and access to care will be taken into consideration during the utilization review.
The documents are provided in Adobe format. If you cannot view a file, please download the free plug-in from the link below.
