Pennsylvania Code
Title 55 - HUMAN SERVICES
Part VI - Mental Health/Intellectual Disability/Autism Manual
Subpart C - Administration and Fiscal Management
Chapter 4220 - REIMBURSEMENT FOR MEDICATIONS
GENERAL REQUIREMENTS
Section 4220.14 - Cost and quality control measures

Universal Citation: 55 PA Code ยง 4220.14

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

(a) It is the responsibility of the county administrator to ensure that the cost of the county program's drug program is kept at an acceptable level and is of professional quality. The county program should establish procedures to ensure that poor prescribing and dispensing practices are eliminated or controlled, and to assist in the continuing education of physicians and pharmacists participating in the county program. In order to ensure maximum acceptance of these procedures, they should be under the direction and guidance of physicians and pharmacists under contract with the county program where possible.

(b) A county spending more than $50,000 per year on drugs shall have a Pharmacy and Therapeutics Review Committee (PTRC) composed of at least a psychiatrist, another physician, a pharmacist, and a representative of the county administrator's office. The PTRC should be of sufficient size to permit a broad representation of viewpoints. Use of a PTRC by a county program spending less than $50,000 per year is optional at the discretion of the county program. The PTRC in a county spending less than $50,000 per year must be composed of at least one psychiatrist, one pharmacist, and a representative of the county administrator's office. A county program may combine resources with another county program to develop a PTRC to serve the county programs involved.

(c) Quality control is the primary function of the PTRC. Through use of the following quality control procedures, significant improvements in the quality of the prescribing and dispensing of medications should be realized in the county program. The following quality control functions should be performed by a PTRC:

(1) Recommendation of guidelines for psycho-pharmacological treatment within the county programs. Guidelines should address issues as: polypharmacy, generic drug dispensing and prescribing, county formulary of reimbursable drugs, prescription quantities and refills, prior approval, and post-audit policies.

(2) Periodic review of the county drug program for patterns of overutilization or drug abuse by patients, inefficient and costly methods of prescribing drugs, inefficient and costly methods of dispensing drugs, or noncompliance with guidelines. When problems are identified the information should be shared with the physician or pharmacist by letter or by personal contact.

(3) Continuing education rather than restrictive actions, is the primary function of the PTRC.

(d) The following cost control measures are available to county programs when taken in consultation with a county PTRC. These measures should only be used when limited resources cause expenditure on medication to impact adversely on other service areas. Caution should be exercised in the use of these measures. The goal of the PTRC program should be to ensure cost benefit and sound practice in the county drug program, while at the same time permitting flexibility, easy access by clients, and encouraging the private model of human service delivery and of the dispensing of drugs.

(1) The county program may establish a formulary of drugs for which it will reimburse and may exclude from that formulary specific drugs or classes of drugs even though they fall in the general categories in § 4220.12(a) (relating to limitations). A county drug formulary must be published at least annually in a newspaper or papers having side circulation in the county program service area.

(2) The county program may establish limits on the total allocation or dollar amount for which it will reimburse.

(3) The county program may require prior approval or post-review by the PTRC for reimbursement to occur. Post-review procedures are to be preferred to prior approval procedures and should be used where possible.

(4) The county program may limit the number of refills to less than one refill, or limit the number of days to fewer than 45 days. The maximum limits under § 4220.12(c) may not be exceeded.

(5) The county program PTRC may conduct a review or audit of pharmacies participating in the Mental Health/Intellectual Disability (MH/ID) drug program to ensure that charges made by the pharmacy to the county program are the usual and customary charges of the pharmacy to the general public.

(6) Where any of the cost control measures under this subsection are enacted, the county administrator must make provision for appeals by prescribers, pharmacies or providers on a "special case" basis.

(7) Cost control measures enacted by county programs under this subsection are subject to review and approval by the Department.

The provisions of this §4220.14 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §§ 4201(2) and (8) and 4202).

Disclaimer: These regulations may not be the most recent version. Pennsylvania 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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