Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 8238 (December 30, 2023).

55 Pa. Code § 1121.55. Method of payment.

§ 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.

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).

Source

   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).

   (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).



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