§ 1121.53. Limitations on payment.
(a) The Department will not pay a provider an amount that exceeds the provider’s usual and customary charge to the general public.
(b) The Department establishes a State MAC which sets a limit on the drug cost component of the payment formula for selected multisource drugs. The State MAC will include a combination of CMS multisource drugs and the Department’s MAC drugs and does not apply if the following exist:
(1) The licensed prescriber certifies that a specific brand is medically necessary by doing all of the following:
(i) Writes on the prescription form ‘‘Brand Necessary’’ or ‘‘Brand Medically Necessary’’ in the prescriber’s own handwriting.
(ii) Receives prior authorization from the Department to use the brand name product.
(2) In the case of a telephone prescription, the licensed prescriber sends a properly completed prescription, as described in paragraph (1), to the pharmacist within 15 days of the date of service.
(Editor’s Note: Under section 2(4) of the act of October 28, 2022 (P.L. 1632, No. 98), § 1121.53(c) is abrogated to the extent that payment for prescriptions is limited to a 34-day supply or 100 units.)
(c) Payment for prescriptions is limited to quantities consistent with the medical needs of the patient not to exceed a 34-day supply or 100 units, whichever is greater. Prescriptions may be refilled as long as the total authorization does not exceed a 6 months’ or five refill supply, whichever comes first, from the time of original filling of the prescription. Refills shall be authorized by the prescriber at the time the prescription is ordered, and the quantity dispensed on the refills may exceed the quantity prescribed on the initial prescription only if noted at the time the licensed prescriber orders the initial prescription.
(d) Payment for prescribed nonlegend drugs shall be limited to drugs and dosage forms listed in the following categories:
(1) Analgesics except long acting products.
(i) Acetaminophen and acetaminophen combinations in the form of tablets, capsules, suppositories, liquids and drops.
(ii) Aspirin and aspirin combinations in the form of tablets, capsules and suppositories.
(iii) Salicylates in the form of tablets, capsules and liquids.
(iv) Ibuprofen in its available dosage forms.
(2) Antacids.
(3) Antidiarrheals.
(i) Kaolin-pectin combinations.
(ii) Loperamide in its available dosage forms.
(4) Antiflatulents.
(i) Simethicone.
(ii) Simethicone combined with antacid.
(5) Antinauseants.
(i) Concentrated balanced solutions of sugar and orthophosphoric acid.
(ii) Cyclizine lactate.
(iii) Dimenhydrinate.
(iv) Meclizine hydrochloride.
(6) Bronchodilators.
(7) Cough—cold preparations, not including mouthwashes, lozenges, troches, throat sprays or rubs, only when prescribed for MA recipients under 21 years of age.
(8) Contraceptives.
(9) Hematinics, not including long acting products.
(i) Ferrous fumarate.
(ii) Ferrous gluconate.
(iii) Ferrous sulfate.
(10) Insulin and disposable insulin syringes.
(11) Laxatives and stool softeners.
(12) Nasal preparations.
(i) Oxymetazoline.
(ii) Phenylephrine.
(iii) Xylometazoline.
(iv) Naphazoline.
(13) Ophthalmic preparations.
(i) Ocular lubricants containing polyvinyl alcohol or cellulose derivatives.
(ii) Phenylephrine in all ophthalmic forms.
(iii) Sodium chloride in strengths of 2% or greater in ophthalmic forms.
(14) Topical products containing one or more of the following active ingredients.
(i) Anesthetics.
(A) Benzocaine.
(B) Cyclomethycaine.
(C) Dibucaine.
(D) Lidocaine.
(E) Pramoxine.
(F) Tetracaine.
(ii) Antibacterials.
(A) Bacitracin.
(B) Neomycin.
(C) Polymyxin.
(D) Povidone-iodine.
(E) Tetracycline.
(iii) Dermatological baths.
(A) Colloidal oatmeal and combinations.
(B) Soya protein complex and combinations.
(iv) Fungicidals.
(A) Iodochlorhydroxyquin (clioquinol).
(B) Miconazole nitrate.
(C) Salicylanilide.
(D) Salicylic acid.
(E) Sodium caprylate.
(F) Sodium proprionate.
(G) Triacetin (glyceryl triacetate).
(H) Tolnaftate.
(I) Undecylenic acid, esters and salts.
(v) Rectal preparations.
(A) Bismuth subgallate.
(B) Yeast.
(C) Zinc oxide.
(vi) Tar preparations, not including soaps and cleansing agents.
(vii) Wet dressings.
(A) Aluminum acetate.
(B) Aluminum sulfate.
(C) Calcium sulfate.
(D) Zinc sulfate.
(15) Vitamins and minerals.
(i) Single entity and multiple vitamins with or without fluoride for children under 3 years of age.
(ii) Single entity and multiple vitamins when prescribed for prenatal use.
(iii) Nicotinic acid and its amides.
(iv) Calcium salts.
(16) Diagnostic agents.
(17) Quinine.
(e) Payment for single entity and multiple vitamins is limited to the following:
(1) Those prescribed, with or without fluorides, for children under 3 years of age.
(2) Those prescribed for prenatal use.
(f) Payment to a pharmacy for prescriptions dispensed to a recipient in either a skilled nursing facility, an intermediate care facility or an intermediate care facility for the mentally retarded shall be limited to one dispensing fee for each drug dispensed within a 30-day period.
Authority The provisions of this § 1121.53 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 § 1121.53 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 August 2, 1991, effective immediately and apply retroactively to July 1, 1989, 21 Pa.B. 3420; amended December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995; amended September 22, 1995, effective October 1, 1995, 25 Pa.B. 3978; amended August 5, 2005, effective August 10, 2005, 35 Pa.B. 4309; amended April 13, 2012, effective April 14, 2012, 42 Pa.B. 2015. Immediately preceding text appears at serial pages (351424) and (312947) to (312949).
(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 55 Pa. Code § 1121.11 (relating to types of services covered); 55 Pa. Code § 1121.51 (relating to general payment policy); 55 Pa. Code § 1121.52 (relating to payment conditions for various services); 55 Pa. Code § 1121.54 (relating to noncompensable services and items); and 55 Pa. Code § 1121.56 (relating to drug cost determination).
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