Section 22.11. General payment principles

(a) Provider billing. A provider is required to bill the Department at the usual charge for the drug dispensed.

(b) Payment elements. A payment to an enrolled provider under the PACE Program shall consist of the following:

(1) The copayment required of claimants on each prescription billed under the PACE Program.

(2) The payment of the generic differential required of claimants under subsection (g).

(3) The approved PACE Program payment.

(c) Program payment calculations. When the Department calculates the approved PACE Program payment, the following requirements apply:

(1) A pharmacy will be paid the lower of the following two amounts:

(i) The average wholesale cost of the prescription drug dispensed, plus the dispensing fee, minus the copayment and, if required under subsection (g), minus the generic differential.

(ii) The pharmacy’s usual charge for the dispensed drug, minus the copayment and, if required under subsection (g), minus the generic differential.

(2) In addition to the approved program payment under paragraph (1), a pharmacy may qualify for a supplemental dispensing fee as provided under subsection (e)(2).

(3) A dispensing physician will be paid the lower of the following two amounts:

(i) The average wholesale cost of the prescription drug dispensed, minus the copayment and, if required under subsection (g), minus the generic differential.

(ii) The dispensing physician’s usual charge minus the copayment and, if required under subsection (g), minus the generic differential.

(d) Copayments.

(1) A claimant of PACE Program benefits is required to pay to the provider the established copayment for each prescription filled under the PACE Program.

(2) The copayment amount for each prescription is $6. The copayment amount will increase or decrease on an annual basis by the average percent change, as determined by the Department, of ingredient costs for prescription drugs dispensed under the program plus a differential to raise the copayment to the next highest 25¢ increment. The Department will publish a notice in the Pennsylvania Bulletin of changes in the copayment amount.

(3) The Department may increase or decrease the amount of the copayment based upon the financial experience and projections of PACE and after consultation with the Pharmaceutical Assistance Review Board. The Department will not approve adjustments to the copayment more frequently than semiannually.

(e) Dispensing fee.

(1) The minimum dispensing fee under the PACE Program will be the dollar amount of the dispensing fee in use under the Medical Assistance Program as specified in 55 Pa. Code § 1121.55(a) (relating to method of payment). A dispensing fee of $2.75 was adopted by the Department as the dispensing fee under the PACE Program effective July 1, 1985. Only pharmacies enrolled in the PACE Program are eligible to receive dispensing fees. A dispensing fee will not be paid to dispensing physicians enrolled in the PACE Program.

(2) When a pharmacy enrolled in the PACE Program can document that, as a result of one of its pharmacist’s consultation with a prescriber, a claimant’s prescription for a higher priced brand name drug, with no substitutions permitted, was changed to permit substitutions and a lower priced generically equivalent drug was dispensed, the Department will pay that pharmacy a supplemental dispensing fee of $1. This fee shall apply only to an original prescription and not to subsequent refills for the same drug. Documentation of the prescription change shall consist of a notation on the back of the original prescription which includes the initials of the pharmacist who consulted with the prescriber, and the date of the consultation.

(f) Special conditions for payment.

(1) A provider shall collect the full copayment required on each prescription filled before the provider submits an allowable claim to the Department for payment. A claim which relates to services for which the full copayment has not been collected will not be considered an allowable claim.

(2) Payments will be made for prescription drugs dispensed by mail when prescription drugs have been ordered and dispensed under this chapter.

(3) A provider who dispenses prescription drugs to PACE claimants by both mail and walk-in procedures will be assigned one number for mail transactions and a second number for walk-in transactions. To be considered a valid claim, a claim submitted to the Department for payment shall be identified as a claim for service by mail or for walk-in service by use of the appropriate provider number. The use of the incorrect provider number shall invalidate a claim and result in a disallowance of the related costs.

(4) A provider of PACE benefits may not charge PACE claimants additional fees above the required copayment and, if applicable, charges due for generic differential costs.

(5) Payment will not be made for prescription drugs dispensed in response to a prescription issued by a prescriber who has been precluded or excluded from the Medicare Program or the Medical Assistance Program for cause or who has committed offenses related to the standards of practice of the medical professions as regulated by the Department of State. This preclusion or exclusion for cause includes voluntary or involuntary termination for cause or voluntary or involuntary suspension for cause. The prescriptions of a prescriber whose name appears on a list issued by the Department of Public Welfare which indicates that the prescriber’s participation in Medicare or Medical Assistance has been precluded or excluded will not be paid for by the PACE Program. The Department will notify providers of prescribers which it learns have been precluded or excluded from the Medical Program or Medical Assistance Program within 30 days of the date when the Department learned of these actions. The Department will reimburse providers for prescriptions written by precluded or excluded prescribers when the prescriptions were filled before the Department’s notification of providers. Prescriptions written by precluded or excluded prescribers which are filled after the Department’s notification are not reimbursable under the PACE Program.

(6) A payment for prescription drugs dispensed under the PACE Program is limited to a prescription filled in a quantity which:

(i) Is consistent with the medical needs of the claimant.

(ii) Does not exceed a 30-day supply or 100 units, whichever is less. The 100 unit limitation applies only to drugs dispensed in tablet or capsule form. Liquids, ointments, powders and other drug forms are subject only to the 30-day supply restriction.

(iii) Does not exceed a 15-day supply and may not be renewed beyond that 15-day period in the case of a prescription for an acute condition.

(iv) Is the maximum supply covered under the act in other cases; that is, a 30-day supply or 100 units, whichever is less, except in cases where the prescriber is utilizing a test dosage to determine the appropriateness of a specific drug for use in maintenance therapy for a chronic condition.

(7) Except for drugs prescribed for acute conditions, payment shall be made for prescriptions refilled up to and including five refills or to provide a 6-month supply, whichever occurs first, from the date of the original filling of the prescription.

(8) Payments will not be made to a claimant or to a party other than an enrolled provider.

(9) PACE Program benefits are not available to cover the costs of filling prescriptions written by prescribers who are not licensed by the Commonwealth unless the pharmacist complies with the following:

(i) At the time of dispensing, the pharmacist shall determine that a physician not licensed by the Commonwealth to practice medicine has a valid license to practice in the District of Columbia or one of the following states: Delaware, Maryland, New Jersey, New York, Ohio, Virigina or West Virginia.

(ii) Under procedures set forth by the Department, the pharmacist shall submit to the Department the name, address, telephone number and appropriate out-of-State physician license number.

(10) Failure by the provider to comply with paragraph (9)(i) and (ii) constitutes grounds for denial of reimbursement under the PACE Program and termination of the provider agreement.

(11) The Department will not pay providers for prescription drugs dispensed when the claimant is outside this Commonwealth.

(12) The Department will not pay providers for dispensing DESI drugs unless the prescription indicates that the prescribed DESI drug is medically necessary.

(13) The Department will not pay a provider for claims for which documentation, as required under § 22.62(c)—(e) (relating to conditions of provider participation), cannot be presented by the provider.

(g) Generic differential.

(1) When a claimant’s prescription permits the substitution of generically equivalent drugs and the claimant requests and purchases a more expensive brand name drug, the claimant is required to pay the provider the generic differential, as defined under § 22.2 (relating to definitions), in addition to the required copayment.

(2) When a claimant’s prescription permits the substitution of a generically equivalent drug, and the provider dispenses a more expensive brand name drug not requested by the claimant, the provider will be charged for the generic differential.

(3) When applicable under paragraphs (1) and (2), the generic differential is 50% of the average wholesale cost, as defined under § 22.2, of the brand name drug dispensed. The Department may increase or decrease the amount of the generic differential based upon the financial experience projections of PACE. Changes will be effective when announced in the Pennsylvania Bulletin.

Example: Usual and custom-
ary charge of drug
demanded by card-
holder … $20
Average wholesale
cost (AWC/AWP) of
drug … $18
Generic differential
(50% OF AWC/AWP) … $9
Copayment … $6
Amount collected by
provider … $15
Amount billed to PACE … $5
(Usual and custom-
ary charge minus
amount collected)

(h) Payment procedures of the Department.

(1) The national drug pricing system currently in use by the Department is ‘‘The Drug Topics Red Book.’’ The Department may change that system after consultation with the Pharmaceutical Assistance Review Board to be effective upon announcement in the Pennsylvania Bulletin.

(2) The Department’s payments to enrolled providers will be remitted within 21 calendar days of the Department’s receipt of a complete and approvable claim.

(3) Claims containing errors or omissions which are the fault of the enrolled provider will be rejected by the Department and returned to the enrolled provider within 21 days of the date of receipt.

(4) Enrolled providers are entitled to interest for payments not remitted by the Department within the 21-day period on complete and approvable claims at a rate to be determined by the Department of Revenue, under section 1507 of The Fiscal Code (72 P. S. § 1507) and approved by the Pharmaceutical Assistance Review Board. Interest payments by the Department will be limited to that time period beginning with the 22nd day and ending with the issuance of payment.

(5) The Department reserves the right to refuse payment of claims submitted more than 90 days after the date the provider dispensed the prescription drugs covered by the claim.

(6) The PACE Program is the payor of last resort. Claimants are required under § § 22.33(1)(ii)(D) and 22.51(1) (relating to responsibilities of the applicant in the application process; and responsibilities regarding eligibility) to inform the Department of coverage they may have under other prescription drug benefit programs. The PACE Program will accept responsibility only for costs not covered by the claimant’s other prescription drug benefit program.

Example—If a claimant purchases a prescription drug costing $15 and has other coverage which provides $7 toward the cost of the prescription, then $6 would be payable by the claimant in the form of a copayment, $7 by the other resource and $2 by PACE.

(i) Other benefits. The Department will be responsible for the coordination and collection of other benefits due in cases where enrolled providers were unable to determine the availability of the other benefits or to secure payment for costs due under the other benefit programs. When PACE benefits have inadvertently been paid to cover costs payable under other prescription benefit programs, the Department will take the necesssary steps to recover those costs plus interest.

The provisions of this § 22.11 adopted June 15, 1984, effective June 16, 1984, 14 Pa.B. 2109; corrected July 6, 1984, effective June 16, 1984, 14 Pa.B. 2331; amended December 13, 1985, effective December 14, 1985, 15 Pa.B. 4427; amended December 14, 1990, effective December 15, 1990, 20 Pa.B. 6143; amended June 14, 1991, effective July 1, 1991, 21 Pa.B. 2722. Immediately preceding text appears at serial pages (153445) to (153451).

Notation

Cross References

This section cited in 6 Pa. Code § 22.2 (relating to definitions); 6 Pa. Code § 22.62 (relating to conditions of provider participation); and 6 Pa. Code § 22.84 (relating to administrative actions and penalties).