CHAPTER 518 - COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS FOR PHARMACY SERVICES

Sep 16, 2026

Uploaded by Levi

Chapter 518 specifies what pharmacy services are covered for Medicaid members, along with the key limitations and exclusions that govern eligibility and utilization. It defines major pricing and reimbursement concepts, outlines covered service categories such as over-the-counter drugs, diabetic testing supplies, home infusion therapy, tobacco cessation, and buprenorphine-based therapies, and identifies non-covered services. The chapter also details service limits, prior authorization requirements and related processes, pharmacy lock-in, drug utilization controls, claim and billing procedures, and reimbursement components including ingredient cost, dispensing fee application, co-payments, and third-party liability coordination.

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CHAPTER 518 – COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS FOR PHARMACY SERVICES

Change Log

Definitions and Covered Service Descriptions

Over-the-Counter and Medical Supplies

Home Infusion Therapy and Tobacco Cessation

Buprenorphine Coverage

Service Limitations and Non-Covered Services

Prior Authorization Process and Related Controls

Drug Utilization and Pharmacy Lock-in

Shipping/Receiving and Claim Submission

Billing Procedure and Reimbursement Components

CHAPTER 518 – COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS FOR PHARMACY SERVICES CHANGE LOG Replace Title Change Date Effective Date | Section 518.1 | Definitions Medicaid AWP
Definitions State MAC (SMAC) | May 1, 2013 | January 1, 2013 | | --- | --- | --- | --- | | Throughout |
May 1, 2013 January 1, 2013 | | | | Section 518.3.1.1 | Mountain Health Choices (MHC) | May 1, 2013 | April 1, 2013 | | Section 518.3.1.3 | Medicaid Members Enrolled in
Medicaid Managed Care Organizational Plans | May 1, 2013 | April 1, 2013 | | Section 518.3.2.1 | AIDS Drug Assistance Program (ADAP) or Ryan White Program | May 1, 2013 | April 1, 2013 | | Section 518.4 | Description of Covered Services May 1, 2013 July 1, 2013 | | | | Section 518.4.2 | Over-the-Counter Drugs | May 1, 2013 | April 1, 2013 | | Section 518.4.3 | Diabetic Testing Supplies and Syringes/Needles | May 1, 2013 | April 1, 2013 | | Section 518.4.5 | Home Infusion Therapy Pharmacy Services | May 1, 2013 | January 1, 2013 | | Section 518.4.6 | Tobacco Cessation Program | May 1, 2013 | April 1, 2013 | | Section 518.4.7 | Buprenorphine-Naloxone (Suboxone®) / Buprenorphine (Subutex®) Coverage May 1, 2013 January 1, 2013 | | | | Section 518.5 | Service Limitation | May 1, 2013 | January 1, 2013 | | Section 518.6 | Coverage of Brand Name Versus Generic Drugs | May 1, 2013 | May 1, 2013 | | Section 518.7 | Non-Covered Services
| May 1, 2013 | January 1, 2013 | | Section 518.8 | Prior Authorization (PA) May 1, 2013 May 1, 2013 | | | | Section 518.8.1 | Process of Requesting Prior May 1, 2013 May 1, 2013
Authorization | | | | Section 518.9.1 | Prospective Drug Utilization | May 1, 2013 | January 1, 2013 | Department of Health and Human Resources Change Log Chapter 518-Pharmacy Services Page 1 Posted July 15, 2013 DISCLAIMER: This manual does not address all the complexities of Medicaid policies and procedures, and must be supplemented with all State and Federal Laws and Regulations. Review (DUR) | Section 518.9.2.1 | Pharmacy Lock-in Program | May 1, 2013 | July 1, 2013 | | --- | --- | --- | --- | | Section 518.10.4 | Shipping/Receiving | May 1, 2013 | May 1, 2013 | | Section 518.11.1 | Point-of-Sale System | May 1, 2013 | January 1, 2013 | | Section 518.11.2 | National Council on Prescription Drug Programs (NCPDP) Payer Sheet | May 1, 2013 | January 1, 2013 | | Section 518.11.3 | Paper Claim Submission for Pharmacy Services | May 1, 2013 | January 1, 2013 | | Section 518.11.10 | Compounded Prescriptions | May 1, 2013 | January 1, 2013 | | Section 518.11.11 | Abuse and Inappropriate Utilization | May 1, 2013 | January 1, 2013 | | Section 518.12 | Reimbursement | May 1, 2013 | January 1, 2013 | | Section 518.12.1 | Ingredient Cost | May 1, 2013 | January 1, 2013 | | Section 518.12.2 | Application of Dispensing Fee | May 1, 2013 | January 1, 2013 | | Section 518.12.3 | Co-Payments | May 1, 2013 | January 1, 2013 | | Section 518.12.4 | Third-Party Liability (TPL) or Coordination of Benefits (COB) | May 1, 2013 | January 1, 2013 | | Section 518.12.4.2 | Medicare Covered Drugs, Part D | May 1, 2013 | January 1, 2013 | | Section 518.13.4 | Additional Information | May 1, 2013 | January 1, 2013 | | Section 518.4 | Description of Covered Services | November 19, 2012 | October 1, 2010 | | Section 518.3.1.4 | Medicaid Members with End Stage Renal Disease (ESRD) | April 1, 2012 | April 1, 2012 | | Section 518.3.2.6 | Juvenile Services | April 1, 2012 | April 1, 2012 | | Section 518.4.5 | Home Infusion Therapy Pharmacy Services, formerly In-Home Parenteral Therapy (IHPT) Pharmacy Services | April 1, 2012 | April 1, 2012 | | Section 518.4.7 | BuprenorphineNaloxone(Suboxone®)/Buprenorphine(Subutex®) Coverage | April 1, 2012 | April 1, 2012 | | Section 518.5.1 | Bulk Chemicals | April 1, 2012 | April 1, 2012 | Department of Health and Human Resources Change Log Chapter 518-Pharmacy Services Page 2 Posted July 15, 2013 DISCLAIMER: This manual does

FAQs

What pharmacy services are covered under Chapter 518?

Chapter 518 covers defined categories including over-the-counter drugs, diabetic testing supplies and syringes/needles, home infusion therapy pharmacy services, tobacco cessation program services, and buprenorphine-naloxone/buprenorphine coverage. It also describes other covered service areas and their effective dates.

How are service limitations and non-covered services handled?

Chapter 518 includes sections for service limitation and non-covered services, clarifying which services are restricted or not reimbursable. It also specifies additional controls such as abuse and inappropriate utilization.

What prior authorization and drug utilization processes apply?

Chapter 518 provides a prior authorization (PA) section, including the process for requesting prior authorization and an appeal process in earlier change log entries. It also addresses prospective drug utilization and related oversight such as the pharmacy lock-in program.

Sep 16, 2026

Uploaded by Levi