Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 140 - MEDICAL PAYMENT
Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES
Section 140.445 - Prescribed Drugs
Universal Citation: 89 IL Admin Code ยง 140.445
Current through Register Vol. 48, No. 38, September 20, 2024
a) Effective July 15, 2019, for prescribed drugs, including prescription and over the counter drugs, the Department shall pay the lower of:
1) the pharmacy's usual and customary charge
to the general public;
2) the
Department's maximum price plus the established professional dispensing fee of
$15.55 for drugs dispensed by Critical Access Pharmacies, as defined in this
subsection, and $8.85 for drugs dispensed by non Critical Access Pharmacies.
The Department shall pay only one dispensing fee per 30 or greater days' supply
for those drugs dispensed in accordance with Section
140.443(h).
For purposes of this section, Critical Access Pharmacies are defined as
pharmacies physically located within Illinois in counties with less than 50,000
residents; and whose owner(s) do not have ownership or control interest in ten
(10) or more pharmacies; and which are brick and mortar, meaning the pharmacy
location is open to the public, recipients present at the pharmacy to fill
prescriptions, and the majority of the pharmacy's business is not mail order
based or through delivery to a residential facility and which is not
owned/operated by a hospital or located within a hospital.;
3) The Department's maximum price is
calculated as the lowest of:
A) Wholesale
Acquisition Cost (WAC) minus 17.5 % for multiple source drugs; WAC minus 4.4 %
for brand name drugs; or WAC minus 10% for blood clotting factor; or
B) National Average Drug Acquisition Cost, if
available; or
C) the Federal upper
limit as established under section 1927(e)(4) of the Social Security Act
(42 USC
1396r-8(e)(4)); or
D) the State upper limit.
b) Effective February 1, 2013, for generic and brand name drugs purchased under the federal drug pricing program established under Section 340B of the federal Public Health Services Act, the Department shall pay the actual acquisition cost for the drug, as billed by the provider, or the Department's established 340B allowable reimbursement rate for the drug, plus a professional dispensing fee of $12.00 for brand and generic drugs.
Disclaimer: These regulations may not be the most recent version. Illinois may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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