§ 1121.54. Noncompensable services and items.
Payment will not be made to a pharmacy for the following services and items:
(1) Drugs and other items prescribed for obesity, appetite control or other similar or related habit altering tendencies. Drugs which have been cleared for use in the treatment of hyperkinesis in children and primary and secondary narcolepsy due to structural damage of the brain are compensable if the physician indicates the diagnosis on the original prescription.
(2) Nonlegend drugs in the form of troches, lozenges, throat tablets, cough drops, chewing gum, mouthwashes and similar items.
(3) Pharmaceutical services provided to a hospitalized person.
(4) Drugs and devices classified as experimental by the FDA or whose use is classified as experimental by the FDA.
(5) Drugs and devices not approved by the FDA or whose use is not approved by the FDA.
(6) Placebos.
(7) Legend and nonlegend soaps, cleansing agents, dentifrices, mouthwashes, douche solutions, diluents, ear wax removal agents, deodorants, liniments, antiseptics, irrigants and other personal care and medicine chest items.
(8) Compounded prescriptions when one of the following applies:
(i) Compensable items are used in less than therapeutic quantities.
(ii) Noncompensable items are compounded.
(9) Nonlegend drugs not listed in § 1121.53(d) (relating to limitations on payment).
(10) Drugs prescribed in conjunction with sex reassignment procedures or other noncompensable procedures.
(11) The following items when prescribed for recipients in a skilled nursing facility, an intermediate care facility or an intermediate care facility for the mentally retarded:
(i) Intravenous solutions.
(ii) Noncompensable drugs and items as specified in this section.
(iii) The following nonlegend drugs:
(A) Analgesics.
(B) Antacids.
(C) Antacids with simethicone.
(D) Cough—cold preparations.
(E) Contraceptives.
(F) Laxative and stool softeners.
(G) Ophthalmic preparations.
(H) Diagnostic agents.
(iv) Legend laxatives.
(12) Items prescribed or ordered by a prescriber who has been barred or suspended from participation in the MA Program. The Department will periodically send pharmacies a list of the names of suspended, terminated or reinstated practitioners and the dates of the various actions. Pharmacies are responsible for checking this list before filling prescriptions.
(13) Prescriptions or orders filled by a pharmacy other than the one to which a recipient has been restricted under § 1101.91 (relating to recipient misutilization and abuse). The Department will issue special medical services eligibility cards to restricted recipients indicating the name of the pharmacy to which the recipient is restricted. Pharmacies are responsible for checking the recipient’s medical services eligibility card before filling the prescription.
(14) DESI drugs and identical, similar or related products or combinations of these products.
(15) A pharmaceutical service for which payment is available from another public agency or another insurance or health program except for those drugs prescribed through the county mental health/mental retardation programs as specified in § 1121.51 (relating to general payment policy).
(16) FDA approved pharmaceutical products whose indicated use is not to treat or manage a medical condition, illness or disorder.
(17) Legend and nonlegend pharmaceutical products distributed by a company that has not entered into a National rebate agreement with the Federal government as provided under section 4401 of OBRA ’90, except for those specific drug products authorized by the Federal government as essential to the health of an MA recipient. The Department will issue a special list comprised of those companies that signed rebate agreements with the Federal government and those products authorized as essential to the health of an MA recipient. Pharmacies are responsible for checking the list before filling the prescription.
(18) Legend and nonlegend cough and cold preparations, except when prescribed for MA recipients under 21 years of age.
(19) Erectile dysfunction drugs unless used for an FDA approved indication other than for the treatment of sexual or erectile dysfunction.
Authority The provisions of this § 1121.54 amended under sections 201(2), 403(b) and 403.1 of the Public Welfare Code (62 P. S. § § 201(2), 403(b) and 403.1).
Source The provisions of this § 1121.54 amended January 16, 1987, effective March 1, 1987, 17 Pa.B. 261; 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 December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995; amended April 13, 2012, effective April 14, 2012, 42 Pa.B. 2015. Immediately preceding text appears at serial pages (312949) to (312952).
Cross References This section cited in 55 Pa. Code § 1121.51 (relating to general payment policy).
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