Current through Register Vol. 54, No. 44, November 2, 2024
(a) The
Department will not pay a provider an amount that exceeds the provider's usual
and customary charge to the general public.
(b) The Department establishes a State MAC
which sets a limit on the drug cost component of the payment formula for
selected multisource drugs. The State MAC will include a combination of CMS
multisource drugs and the Department's MAC drugs and does not apply if the
following exist:
(1) The licensed prescriber
certifies that a specific brand is medically necessary by doing all of the
following:
(i) Writes on the prescription form
"Brand Necessary" or "Brand Medically Necessary" in the prescriber's own
handwriting.
(ii) Receives prior
authorization from the Department to use the brand name product.
(2) In the case of a telephone
prescription, the licensed prescriber sends a properly completed prescription,
as described in paragraph (1), to the pharmacist within 15 days of the date of
service.
(Editor's Note: Under section 2(4) of the
act of October 28, 2022 (P.L. 1632, No. 98), §
1121.53(c) is
abrogated to the extent that payment for prescriptions is limited to a 34-day
supply or 100 units.)
(c) Payment for prescriptions is limited to
quantities consistent with the medical needs of the patient not to exceed a
34-day supply or 100 units, whichever is greater. Prescriptions may be refilled
as long as the total authorization does not exceed a 6 months' or five refill
supply, whichever comes first, from the time of original filling of the
prescription. Refills shall be authorized by the prescriber at the time the
prescription is ordered, and the quantity dispensed on the refills may exceed
the quantity prescribed on the initial prescription only if noted at the time
the licensed prescriber orders the initial prescription.
(d) Payment for prescribed nonlegend drugs
shall be limited to drugs and dosage forms listed in the following categories:
(1) Analgesics except long acting products.
(i) Acetaminophen and acetaminophen
combinations in the form of tablets, capsules, suppositories, liquids and
drops.
(ii) Aspirin and aspirin
combinations in the form of tablets, capsules and suppositories.
(iii) Salicylates in the form of tablets,
capsules and liquids.
(iv)
Ibuprofen in its available dosage forms.
(2) Antacids.
(3) Antidiarrheals.
(i) Kaolin-pectin combinations.
(ii) Loperamide in its available dosage
forms.
(4)
Antiflatulents.
(i) Simethicone.
(ii) Simethicone combined with
antacid.
(5)
Antinauseants.
(i) Concentrated balanced
solutions of sugar and orthophosphoric acid.
(ii) Cyclizine lactate.
(iii) Dimenhydrinate.
(iv) Meclizine hydrochloride.
(6) Bronchodilators.
(7) Cough-cold preparations, not including
mouthwashes, lozenges, troches, throat sprays or rubs, only when prescribed for
MA recipients under 21 years of age.
(8) Contraceptives.
(9) Hematinics, not including long acting
products.
(i) Ferrous fumarate.
(ii) Ferrous gluconate.
(iii) Ferrous sulfate.
(10) Insulin and disposable insulin
syringes.
(11) Laxatives and stool
softeners.
(12) Nasal preparations.
(i) Oxymetazoline.
(ii) Phenylephrine.
(iii) Xylometazoline.
(iv) Naphazoline.
(13) Ophthalmic preparations.
(i) Ocular lubricants containing polyvinyl
alcohol or cellulose derivatives.
(ii) Phenylephrine in all ophthalmic
forms.
(iii) Sodium chloride in
strengths of 2% or greater in ophthalmic forms.
(14) Topical products containing one or more
of the following active ingredients.
(i)
Anesthetics.
(A) Benzocaine.
(B) Cyclomethycaine.
(C) Dibucaine.
(D) Lidocaine.
(E) Pramoxine.
(F) Tetracaine.
(ii) Antibacterials.
(A) Bacitracin.
(B) Neomycin.
(C) Polymyxin.
(D) Povidone-iodine.
(E) Tetracycline.
(iii) Dermatological baths.
(A) Colloidal oatmeal and
combinations.
(B) Soya protein
complex and combinations.
(iv) Fungicidals.
(A) Iodochlorhydroxyquin
(clioquinol).
(B) Miconazole
nitrate.
(C)
Salicylanilide.
(D) Salicylic
acid.
(E) Sodium
caprylate.
(F) Sodium
proprionate.
(G) Triacetin
(glyceryl triacetate).
(H)
Tolnaftate.
(I) Undecylenic acid,
esters and salts.
(v)
Rectal preparations.
(A) Bismuth
subgallate.
(B) Yeast.
(C) Zinc oxide.
(vi) Tar preparations, not including soaps
and cleansing agents.
(vii) Wet
dressings.
(A) Aluminum acetate.
(B) Aluminum sulfate.
(C) Calcium sulfate.
(D) Zinc sulfate.
(15) Vitamins and minerals.
(i) Single entity and multiple vitamins with
or without fluoride for children under 3 years of age.
(ii) Single entity and multiple vitamins when
prescribed for prenatal use.
(iii)
Nicotinic acid and its amides.
(iv)
Calcium salts.
(16)
Diagnostic agents.
(17)
Quinine.
(e) Payment for
single entity and multiple vitamins is limited to the following:
(1) Those prescribed, with or without
fluorides, for children under 3 years of age.
(2) Those prescribed for prenatal
use.
(f) Payment to a
pharmacy for prescriptions dispensed to a recipient in either a skilled nursing
facility, an intermediate care facility or an intermediate care facility for
the mentally retarded shall be limited to one dispensing fee for each drug
dispensed within a 30-day period.
This regulation was promulgated under section 6(b) of the
Regulatory Review Act (71 P. S. §
745.6(b)).
The provisions of this §1121.53 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 55 Pa. Code §
1121.11 (relating to types of
services covered); 55 Pa. Code §
1121.51 (relating to general
payment policy); 55 Pa. Code §
1121.52 (relating to payment
conditions for various services); 55 Pa. Code §
1121.54 (relating to
noncompensable services and items); and 55 Pa. Code §
1121.56 (relating to drug cost
determination).
