6 Pa. Code § 22.11 - General payment principles
(a)
Provider billing. A provider is required to bill the
Department at the usual charge for the drug dispensed.
(b)
Payment elements. A
payment to an enrolled provider under the PACE Program shall consist of the
following:
(1) The copayment required of
claimants on each prescription billed under the PACE Program.
(2) The payment of the generic differential
required of claimants under subsection (g).
(3) The approved PACE Program
payment.
(c)
Program payment calculations. When the Department calculates
the approved PACE Program payment, the following requirements apply:
(1) A pharmacy will be paid the lower of the
following two amounts:
(i) The average
wholesale cost of the prescription drug dispensed, plus the dispensing fee ,
minus the copayment and, if required under subsection (g), minus the generic
differential .
(ii) The pharmacy 's
usual charge for the dispensed drug, minus the copayment and, if required under
subsection (g), minus the generic differential .
(2) In addition to the approved program
payment under paragraph (1), a pharmacy may qualify for a supplemental
dispensing fee as provided under subsection (e)(2).
(3) A dispensing physician will be paid the
lower of the following two amounts:
(i) The
average wholesale cost of the prescription drug dispensed, minus the copayment
and, if required under subsection (g), minus the generic
differential .
(ii) The dispensing
physician 's usual charge minus the copayment and, if required under subsection
(g), minus the generic differential .
(d)
Copayments.
(1) A claimant of PACE Program benefits is
required to pay to the provider the established copayment for each prescription
filled under the PACE Program.
(2)
The copayment amount for each prescription is $6. The copayment amount will
increase or decrease on an annual basis by the average percent change, as
determined by the Department , of ingredient costs for prescription drugs
dispensed under the program plus a differential to raise the copayment to the
next highest 25¢ increment. The Department will publish a notice in the
Pennsylvania Bulletin of changes in the copayment
amount.
(3) The Department may
increase or decrease the amount of the copayment based upon the financial
experience and projections of PACE and after consultation with the
Pharmaceutical Assistance Review Board . The Department will not approve
adjustments to the copayment more frequently than semiannually.
(e)
Dispensing
fee .
(1) The minimum dispensing fee
under the PACE Program will be the dollar amount of the dispensing fee in use
under the Medical Assistance Program as specified in 55 Pa. Code §1121.55(a)
(relating to method of payment). A dispensing fee of $2.75 was adopted by the
Department as the dispensing fee under the PACE Program effective July 1, 1985.
Only pharmacies enrolled in the PACE Program are eligible to receive dispensing
fees. A dispensing fee will not be paid to dispensing physicians enrolled in
the PACE Program.
(2) When a
pharmacy enrolled in the PACE Program can document that, as a result of one of
its pharmacist's consultation with a prescriber , a claimant 's prescription for
a higher priced brand name drug, with no substitutions permitted, was changed
to permit substitutions and a lower priced generically equivalent drug was
dispensed, the Department will pay that pharmacy a supplemental dispensing fee
of $1. This fee shall apply only to an original prescription and not to
subsequent refills for the same drug. Documentation of the prescription change
shall consist of a notation on the back of the original prescription which
includes the initials of the pharmacist who consulted with the prescriber , and
the date of the consultation.
(f)
Special conditions for
payment.
(1) A provider shall
collect the full copayment required on each prescription filled before the
provider submits an allowable claim to the Department for payment. A claim
which relates to services for which the full copayment has not been collected
will not be considered an allowable claim .
(2) Payments will be made for prescription
drugs dispensed by mail when prescription drugs have been ordered and dispensed
under this chapter.
(3) A provider
who dispenses prescription drugs to PACE claimants by both mail and walk-in
procedures will be assigned one number for mail transactions and a second
number for walk-in transactions. To be considered a valid claim , a claim
submitted to the Department for payment shall be identified as a claim for
service by mail or for walk-in service by use of the appropriate provider
number. The use of the incorrect provider number shall invalidate a claim and
result in a disallowance of the related costs.
(4) A provider of PACE benefits may not
charge PACE claimants additional fees above the required copayment and, if
applicable, charges due for generic differential costs.
(5) Payment will not be made for prescription
drugs dispensed in response to a prescription issued by a prescriber who has
been precluded or excluded from the Medicare Program or the Medical Assistance
Program for cause or who has committed offenses related to the standards of
practice of the medical professions as regulated by the Department of State.
This preclusion or exclusion for cause includes voluntary or involuntary
termination for cause or voluntary or involuntary suspension for cause. The
prescriptions of a prescriber whose name appears on a list issued by the
Department of Public Welfare which indicates that the prescriber 's
participation in Medicare or Medical Assistance has been precluded or excluded
will not be paid for by the PACE Program. The Department will notify providers
of prescribers which it learns have been precluded or excluded from the Medical
Program or Medical Assistance Program within 30 days of the date when the
Department learned of these actions. The Department will reimburse providers
for prescriptions written by precluded or excluded prescribers when the
prescriptions were filled before the Department 's notification of providers.
Prescriptions written by precluded or excluded prescribers which are filled
after the Department 's notification are not reimbursable under the PACE
Program.
(6) A payment for
prescription drugs dispensed under the PACE Program is limited to a
prescription filled in a quantity which:
(i)
Is consistent with the medical needs of the claimant .
(ii) Does not exceed a 30-day supply or 100
units, whichever is less. The 100 unit limitation applies only to drugs
dispensed in tablet or capsule form. Liquids, ointments, powders and other drug
forms are subject only to the 30-day supply restriction.
(iii) Does not exceed a 15-day supply and may
not be renewed beyond that 15-day period in the case of a prescription for an
acute condition .
(iv) Is the
maximum supply covered under the act in other cases; that is, a 30-day supply
or 100 units, whichever is less, except in cases where the prescriber is
utilizing a test dosage to determine the appropriateness of a specific drug for
use in maintenance therapy for a chronic condition.
(7) Except for drugs prescribed for acute
conditions, payment shall be made for prescriptions refilled up to and
including five refills or to provide a 6-month supply, whichever occurs first,
from the date of the original filling of the prescription.
(8) Payments will not be made to a claimant
or to a party other than an enrolled provider .
(9) PACE Program benefits are not available
to cover the costs of filling prescriptions written by prescribers who are not
licensed by the Commonwealth unless the pharmacist complies with the following:
(i) At the time of dispensing , the pharmacist
shall determine that a physician not licensed by the Commonwealth to practice
medicine has a valid license to practice in the District of Columbia or one of
the following states: Delaware, Maryland, New Jersey, New York, Ohio, Virigina
or West Virginia.
(ii) Under
procedures set forth by the Department , the pharmacist shall submit to the
Department the name, address, telephone number and appropriate out-of-State
physician license number.
(10) Failure by the provider to comply with
paragraph (9)(i) and (ii) constitutes grounds for denial of reimbursement under
the PACE Program and termination of the provider agreement.
(11) The Department will not pay providers
for prescription drugs dispensed when the claimant is outside this
Commonwealth.
(12) The Department
will not pay providers for dispensing DESI drugs unless the prescription
indicates that the prescribed DESI drug is medically necessary.
(13) The Department will not pay a provider
for claims for which documentation, as required under §
22.62(c)-(e)
(relating to conditions of provider participation), cannot be presented by the
provider.
(g)
Generic differential .
(1)
When a claimant 's prescription permits the substitution of generically
equivalent drugs and the claimant requests and purchases a more expensive brand
name drug, the claimant is required to pay the provider the generic
differential , as defined under §
22.2 (relating to definitions), in
addition to the required copayment .
(2) When a claimant 's prescription permits
the substitution of a generically equivalent drug, and the provider dispenses a
more expensive brand name drug not requested by the claimant , the provider will
be charged for the generic differential .
(3) When applicable under paragraphs (1) and
(2), the generic differential is 50% of the average wholesale cost , as defined
under §
22.2, of the brand name drug dispensed. The Department may
increase or decrease the amount of the generic differential based upon the
financial experience projections of PACE . Changes will be effective when
announced in the Pennsylvania Bulletin.
Example: Usual and customary charge of drug demanded by card- holder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20
Amount collected by provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15
Amount billed to
(Usual and customary charge minus amount collected)
(h)
Payment procedures of the Department .
(1) The national drug pricing system
currently in use by the Department is "The Drug Topics Red Book." The
Department may change that system after consultation with the Pharmaceutical
Assistance Review Board to be effective upon announcement in the
Pennsylvania Bulletin.
(2) The Department 's payments to enrolled
providers will be remitted within 21 calendar days of the Department 's receipt
of a complete and approvable claim .
(3) Claims containing errors or omissions
which are the fault of the enrolled provider will be rejected by the Department
and returned to the enrolled provider within 21 days of the date of
receipt.
(4) Enrolled providers are
entitled to interest for payments not remitted by the Department within the
21-day period on complete and approvable claims at a rate to be determined by
the Department of Revenue, under section 1507 of The Fiscal Code (72 P. S. §
1507) and approved by the Pharmaceutical
Assistance Review Board . Interest payments by the Department will be limited to
that time period beginning with the 22nd day and ending with the issuance of
payment.
(5) The Department
reserves the right to refuse payment of claims submitted more than 90 days
after the date the provider dispensed the prescription drugs covered by the
claim .
(6) The PACE Program is the
payor of last resort. Claimants are required under §§
22.33(1)(ii)(D)
and 22.51(1)
(relating to responsibilities of the applicant in the application process; and
responsibilities regarding eligibility) to inform the Department of coverage
they may have under other prescription drug benefit programs. The PACE Program
will accept responsibility only for costs not covered by the claimant 's other
prescription drug benefit program.
Example-If a
(i)
Other benefits. The
Department will be responsible for the coordination and collection of other
benefits due in cases where enrolled providers were unable to determine the
availability of the other benefits or to secure payment for costs due under the
other benefit programs. When PACE benefits have inadvertently been paid to
cover costs payable under other prescription benefit programs, the Department
will take the necesssary steps to recover those costs plus interest.
Notes
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