Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 119 - ILLINOIS CARES RX PROGRAM (REPEALED)
Section 119.100 - Pharmacy Payment
Universal Citation: 89 IL Admin Code ยง 119.100
Current through Register Vol. 48, No. 12, March 22, 2024
a) Direct payment to pharmacies by the Department is made only for pharmaceutical products for individuals not enrolled in Medicare Part D or for Medicare Part D excluded pharmaceutical products covered by the Department when dispensed to individuals enrolled in Medicare Part D.
b) Reimbursable Amount
1) Except as provided in subsections (b)(2),
(3) and (4) of this Section, the reimbursable amount for a pharmaceutical
product eligible for direct payment by the Department shall be:
A) For legend (prescription) drugs, the
Department shall pay the lower of:
i) the
pharmacy's prevailing charge to the general public; or
ii) the Department's maximum price plus a
dispensing fee of $2.25 for both generic and brand name drugs less applicable
co-payments and cost sharing as set forth in Section
119.90.
B) For generic drugs, the
Department's maximum price is calculated as the lowest of:
i) the average wholesale price minus 25
percent; or
ii) the Federal Upper
Limit; or
iii) the State Upper
Limit.
C) For brand name
drugs, the Department's maximum price is calculated as the average wholesale
price minus 14 percent.
D) For
those over-the-counter drugs that are covered, the Department shall pay the
lower of:
i) the pharmacy's prevailing charge
to the general public; or
ii) the
average wholesale price plus 25 percent; or
iii) the State Upper Limit.
2) If a generic drug is
available, based upon the Illinois Formulary for Drug Product Selection Program
(77 Ill. Adm. Code 790), and the individual wants the brand name equivalent of
the drug, the reimbursable amount shall be that of the generic drug.
3) If a brand name drug is dispensed when the
reimbursable amount is that for the generic drug, the individual shall be
responsible for paying the difference between the reimbursable amount (based
upon the generic drug) and what would have been the reimbursable amount for the
brand name drug, plus the applicable co-payment and cost sharing, as described
in Section 119.90.
4) Payment by
the Department to a participating pharmacy for a pharmaceutical product
dispensed to an individual eligible for Illinois Cares Rx shall be the
difference of the reimbursable amount, as described in subsection (b) of this
Section, less applicable co-payments, and cost sharing, as described in Section
119.90, and any amount paid or payable by Medicare or another third party as
described at 89 Ill. Adm. Code
140.12(h)(2).
5) The reimbursable amount to pharmacies for
prescriptions processed by a Medicare Part D PDP shall be at the contracted
rate between the pharmacy and the PDP.
c) Provider Participation
In order to bill the Department directly for prescriptions dispensed to participants in the Illinois Cares Rx Program, pharmacies shall be enrolled in the Medical Assistance Program under Article V of the Public Aid Code.
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