CHAPTER 4220. REIMBURSEMENT FOR MEDICATIONS
GENERAL PROVISIONS Sec.
4220.1. Purpose.
4220.2. Applicability.
4220.3. Legal base.
GENERAL REQUIREMENTS
4220.11. Purchase of drugs.
4220.12. Limitations.
4220.13. Procedures.
4220.14. Cost and quality control measures.Authority The provisions of this Chapter 4220 issued under section 201 of the Mental Health and Mental Retardation Act of 1966 (50 P.S. § 4201), unless otherwise noted.
Source The provisions of this Chapter 4220 adopted December 29, 1978, effective January 29, 1979, unless otherwise noted.
Cross References This chapter cited in 55 Pa. Code § 4300.118 (relating to special limitations on unit of service funding).
GENERAL PROVISIONS
§ 4220.1. Purpose.
This chapter specifies requirements pertaining to reimbursement by the county mental health and intellectual disability program for the cost of drugs.
Authority The provisions of this § 4220.1 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4220.1 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (247749).
§ 4220.2. Applicability.
This chapter applies to county mental health and intellectual disability programs.
Authority The provisions of this § 4220.2 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4220.2 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (247749).
§ 4220.3. Legal base.
The legal authority for this chapter is section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).
Authority The provisions of this § 4220.3 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4220.3 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (247749).
GENERAL REQUIREMENTS
§ 4220.11. Purchase of drugs.
(a) For the cost of a drug to be reimbursed by the county mental health and intellectual disability program it must be prescribed by a practitioner licensed by statute to prescribe the drugs and must be specifically for the mental disorder under treatment. Client liability and third party revenues must be exhausted before county mental health and intellectual disability funds are used.
(b) For a pharmacy to receive reimbursement from the county mental health and intellectual disability program it must be licensed by the State Board of Pharmacy.
Authority The provisions of this § 4220.11 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4220.11 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (247750).
§ 4220.12. Limitations.
(a) Drugs in the following general categories may be reimbursed by the county mental health and intellectual disability program.
(1) Major tranquilizers. Includes:
(i) Phenothiazines.
(ii) Butyrophenones.
(iii) Thioxanthenes.
(iv) Rauwolfia Alkaloids.
(v) Dibenzoxazepines.
(vi) Molindones.
(2) Minor tranquilizers. Includes:
(i) Propanediole.
(ii) Benzodiazepines.
(iii) Diphenylmethane Derivatives.
(3) Hypnotics and sedatives. Includes:
(i) Barbiturates.
(ii) Nonbarbiturates.
(4) Antidepressants. Includes:
(i) Tricyclics.
(ii) Monomine Oxidase Inhibiters.
(iii) Lithium.
(5) Central nervous system stimulants.
(6) Anticonvulsant agents.
(7) Antiparkinsonian agents.
(8) Various geriatric psychotropic agents.
(b) The county mental health and intellectual disability program may also reimburse for an item not falling in the general categories listed in subsection (a)(1)—(8) if, in the licensed practitioner’s professional opinion, it is essential for the present treatment of the patient’s mental disorder. The county mental health and intellectual disability program may require, as a condition of reimbursement for these items, that prior approval be given by the County MH/ID Program. Where prior approval is required, it is the responsibility of the county administrator to ensure that proper notification of approval be given to the pharmacy at the time the prescription is presented to be filled.
(c) An initial prescription is limited to a 45-day supply and a maximum of one refill may be requested on an initial prescription. The quantity dispensed on the refill prescription cannot exceed the quantity prescribed on the initial prescription.
(d) The County MH/ID Program’s maximum rate of reimbursement for drugs is the pharmacy’s usual and customary charges to the general public for psychotropic drugs. Discounts given to special groups such as senior citizens must also be given to County MH/ID clients who are members of those specialized groups.
Authority The provisions of this § 4220.12 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4220.12 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial pages (247750) to (247751).
Cross References This section cited in 55 Pa. Code § 4220.14 (relating to cost and quality control measures).
§ 4220.13. Procedures.
(a) The prescription must be made on Prescription and Pharmacist’s Invoice, Form MH/ID 12. The number of refills permitted—not to exceed one—should be indicated on the MH/ID 12. It is the responsibility of the physician to ensure that the patient’s drug costs are eligible for reimbursement by the County MH/ID Program and have been authorized for payment by the county administrator before using an MH/ID 12 prescription form.
(b) The pharmacy submits the MH/ID 12 on a monthly basis to the county MH/ID administrator for reimbursement. Refills of prescriptions should be reported to the county program on a monthly basis on a form of the county program’s choosing.
(c) The county administrator is responsible for providing authorization for purchase of medication. The county administrator is also responsible for ensuring that the invoice is correctly priced and is for eligible drugs. The county administrator makes payment to the pharmacy for invoices submitted under subsection (b). It is the responsibility of the county administrator to ensure that patient liability and third party revenues are exhausted before County Mental Health/Intellectual Disability (MH/ID) funds are used. This responsibility may be delegated; however, the county administrator shall make every effort to ensure that pharmacies are reimbursed in a timely fashion. The goal should be reimbursement within 30 days of receipt of the claim.
Authority The provisions of this § 4220.13 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4220.13 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial page (247751).
§ 4220.14. Cost and quality control measures.
(a) It is the responsibility of the county administrator to ensure that the cost of the county program’s drug program is kept at an acceptable level and is of professional quality. The county program should establish procedures to ensure that poor prescribing and dispensing practices are eliminated or controlled, and to assist in the continuing education of physicians and pharmacists participating in the county program. In order to ensure maximum acceptance of these procedures, they should be under the direction and guidance of physicians and pharmacists under contract with the county program where possible.
(b) A county spending more than $50,000 per year on drugs shall have a Pharmacy and Therapeutics Review Committee (PTRC) composed of at least a psychiatrist, another physician, a pharmacist, and a representative of the county administrator’s office. The PTRC should be of sufficient size to permit a broad representation of viewpoints. Use of a PTRC by a county program spending less than $50,000 per year is optional at the discretion of the county program. The PTRC in a county spending less than $50,000 per year must be composed of at least one psychiatrist, one pharmacist, and a representative of the county administrator’s office. A county program may combine resources with another county program to develop a PTRC to serve the county programs involved.
(c) Quality control is the primary function of the PTRC. Through use of the following quality control procedures, significant improvements in the quality of the prescribing and dispensing of medications should be realized in the county program. The following quality control functions should be performed by a PTRC:
(1) Recommendation of guidelines for psycho-pharmacological treatment within the county programs. Guidelines should address issues as: polypharmacy, generic drug dispensing and prescribing, county formulary of reimbursable drugs, prescription quantities and refills, prior approval, and post-audit policies.
(2) Periodic review of the county drug program for patterns of overutilization or drug abuse by patients, inefficient and costly methods of prescribing drugs, inefficient and costly methods of dispensing drugs, or noncompliance with guidelines. When problems are identified the information should be shared with the physician or pharmacist by letter or by personal contact.
(3) Continuing education rather than restrictive actions, is the primary function of the PTRC.
(d) The following cost control measures are available to county programs when taken in consultation with a county PTRC. These measures should only be used when limited resources cause expenditure on medication to impact adversely on other service areas. Caution should be exercised in the use of these measures. The goal of the PTRC program should be to ensure cost benefit and sound practice in the county drug program, while at the same time permitting flexibility, easy access by clients, and encouraging the private model of human service delivery and of the dispensing of drugs.
(1) The county program may establish a formulary of drugs for which it will reimburse and may exclude from that formulary specific drugs or classes of drugs even though they fall in the general categories in § 4220.12(a) (relating to limitations). A county drug formulary must be published at least annually in a newspaper or papers having side circulation in the county program service area.
(2) The county program may establish limits on the total allocation or dollar amount for which it will reimburse.
(3) The county program may require prior approval or post-review by the PTRC for reimbursement to occur. Post-review procedures are to be preferred to prior approval procedures and should be used where possible.
(4) The county program may limit the number of refills to less than one refill, or limit the number of days to fewer than 45 days. The maximum limits under § 4220.12(c) may not be exceeded.
(5) The county program PTRC may conduct a review or audit of pharmacies participating in the Mental Health/Intellectual Disability (MH/ID) drug program to ensure that charges made by the pharmacy to the county program are the usual and customary charges of the pharmacy to the general public.
(6) Where any of the cost control measures under this subsection are enacted, the county administrator must make provision for appeals by prescribers, pharmacies or providers on a ‘‘special case’’ basis.
(7) Cost control measures enacted by county programs under this subsection are subject to review and approval by the Department.
Authority The provisions of this § 4220.14 amended under sections 201(2) and (8) and 202 of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § § 4201(2) and (8) and 4202).
Source The provisions of this § 4220.14 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177. Immediately preceding text appears at serial pages (247751) to (247753).
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