55 Pa. Code § 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.
Notes
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).
This section cited in 55 Pa. Code § 1121.51 (relating to general payment policy).
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