Section 1121.55. Method of payment

(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.

The provisions of this § 1121.55 amended August 10, 1984, effective September 1, 1984, 14 Pa.B. 2926; amended January 16, 1987, effective March 1, 1987, 17 Pa.B. 261; amended December 14, 1990, effective January 11, 1991, 20 Pa.B. 6167; amended January 24, 1992, effective April 1, 1991, for the Manufacturers’ Rebate Program and September 1, 1991 for the pharmacy dispensing fee increase, 22 Pa.B. 361; amended September 22, 1995, effective October 1, 1995, 25 Pa.B. 3978; amended April 13, 2012, effective April 14, 2012, 42 Pa.B. 2015. Immediately preceding text appears at serial page (312952).

Notation

Authority

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).

(Editor’s Note: This regulation was promulgated under section 6(b) of the Regulatory Review Act (71 P. S. § 745.6(b)).)

Cross References

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).