Current through Register Vol. 54, No. 24, June 15, 2024
Section 1121.55 - Method of payment(a) The Department will pay a pharmacy for a compensable legend and nonlegend drug (after deducting the applicable copayment amount, as described in § 1101.63(b) (relating to payment in full)), the lowest of the following amounts: (1) The EAC for the drug, multiplied by the number of units dispensed, plus a $2 dispensing fee.(2) The State MAC for the drug, multiplied by the number of units dispensed, plus a $2 dispensing fee.(3) The provider's usual and customary charge to the general public.(4) For MA recipients with a pharmacy benefit resource which is a primary third party payer to MA, the lower of the following amounts: (i) The EAC for the drug, multiplied by the number of units dispensed, plus a $0.50 dispensing fee.(ii) The State MAC, multiplied by the number of units dispensed, plus a $0.50 dispensing fee.(b) The Department will pay a pharmacy for a compensable compounded prescription at the lower of the cost of all ingredients plus a $3 dispensing fee or the provider's usual and customary charge to the general public. For MA recipients with a pharmacy benefit resource which is a primary third party payer to MA, the dispensing fee shall be $0.50.(c) The provider shall bill the Department at its usual and customary charge to the general public.The provisions of this § 1121.55 amended August 10, 1984, effective 9/1/1984, 14 Pa.B. 2926; amended January 16, 1987, effective 3/1/1987, 17 Pa.B. 261; amended December 14, 1990, effective 1/11/1991, 20 Pa.B. 6167; amended January 24, 1992, effective 4/1/1991, for the Manufacturers' Rebate Program and September 1, 1991 for the pharmacy dispensing fee increase, 22 Pa.B. 361; amended September 22, 1995, effective 10/1/1995, 25 Pa.B. 3978; amended April 13, 2012, effective 4/14/2012, 42 Pa.B. 2015.This regulation was promulgated under section 6(b) of the Regulatory Review Act (71 P. S. § 745.6(b)).
The provisions of this § 1121.55 amended under sections 201, 403, 403.1 and 443.4 of the Public Welfare Code (62 P. S. §§ 201, 403, 403.1 and 443.4).
This section cited in 6 Pa. Code § 22.11 (relating to general payment principles); 49 Pa. Code § 27.505 (relating to repositories); and 55 Pa. Code § 1121.51 (relating to general payment policy).