Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1121 - PHARMACEUTICAL SERVICES
PAYMENT FOR PHARMACEUTICAL SERVICES
Section 1121.55 - Method of payment

Universal Citation: 55 PA Code ยง 1121.55

Current through Register Vol. 54, No. 44, November 2, 2024

(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.

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).

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