Current through Register 1531, September 27, 2024
(1)
Payment for Multiple Source Drugs. Payment for
multiple source drugs not designated as Brand Name Preferred and not certified
as medically necessary (i.e., drugs for which the prescriber
has not designated "no substitution" and "brand name medically necessary" on
the prescription form), other than blood clotting factor and drugs obtained
through the 340B Drug Pricing Program, must not exceed the lowest of
(a) the Federal Upper Limit of the drug, if
any, plus the appropriate dispensing fee as listed in
101 CMR 331.06;
or
(b) the Massachusetts Maximum
Allowable Cost of the drug, if any, plus the appropriate dispensing fee as
listed in
101 CMR 331.06;
or
(c) the AAC of the drug, plus
the appropriate dispensing fee as listed in
101 CMR 331.06;
or
(d) the usual and customary
charge.
(2)
Payment for Blood Clotting Factor. Payment for blood
clotting factor not obtained through the 340B Drug Pricing Program must not
exceed the lowest of
(a) the Federal Upper
Limit of the drug, if any, plus the appropriate dispensing fee as listed in
101 CMR 331.06;
or
(b) the AAC of the drug, plus
the appropriate dispensing fee as listed in
101 CMR 331.06;
or
(c) 106% of the Average Sales
Price of the drug, plus the appropriate dispensing fee as listed in
101 CMR 331.06;
or
(d) the usual and customary
charge.
(3)
Payment for All Other Drugs. Payment for all other
drugs not priced in accordance with 101 CMR 331.04(1) or (2), and not obtained
through the 340B Drug Pricing Program, including single source drugs, multiple
source drugs designated as Brand Name Preferred, and brand name drugs which
have been certified as medically necessary (i.e., drugs for
which the prescriber has designated "no substitution" and "brand name medically
necessary" on the prescription form), must not exceed the lowest of
(a) The Massachusetts Maximum Allowable Cost
of the drug, if any, plus the appropriate dispensing fee as listed in
101 CMR 331.06;
or
(b) The AAC of the drug, plus
the appropriate dispensing fee as listed in
101 CMR 331.06;
or
(c) The usual and customary
charge.
(4)
Rate Limitation.
(a)
Payments for multiple source drugs for which CMS has established Federal Upper
Limits, and that have not been certified as medically necessary
(i.e., drugs for which the prescriber has not designated "no
substitution" and "brand name medically necessary" on the prescription form),
must not exceed, in the aggregate and prior to the application of an federal or
state drug rebates, the aggregate upper limit based on those Federal Upper
Limits, regardless of whether payment amounts for individual drugs are
determined pursuant to 101 CMR 331.04(1) or (3).
(b) Payments for multiple source drugs that
have been certified as medically necessary (i.e., drugs for
which the prescriber has designated "no substitution" and "brand name medically
necessary" on the prescription form), must not exceed, in the aggregate and
prior to the application of federal or state drug rebates, the lower of AAC
plus the appropriate dispensing fee as listed in
101 CMR 331.06
and the usual and customary charge.
