Current through Register Vol. 54, No. 45, November 9, 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).