1. (a) The Department will not pay a provider an amount that exceeds the provider’s usual and customary charge to the general public.

2. (b) CMS establishes a FUL and the Department establishes a State MAC which set a limit on the drug cost component of the payment formula for selected multisource drugs. The FUL and the State MAC do not apply if the following exist:

   1. (1) The licensed prescriber certifies that a specific brand is medically necessary by doing all of the following:

      1. (i) Writes on the prescription form ‘‘Brand Necessary’’ or ‘‘Brand Medically Necessary’’ in the licensed prescriber’s own handwriting or by an electronic alternative means as clarified in § 1121.52a (relating to clarification of the term ‘‘written’’—statement of policy).
      2. (ii) Receives prior authorization from the Department to use the brand name product.
   2. (2) {Reserved}.
3. (c) Payment for prescriptions, with the exception of systemic contraceptives, is limited to no more than a 90-day supply or 100 units, whichever is greater. Payment for systemic contraceptives is limited to no more than a 1-year supply. Prescriptions may be refilled in accordance with 49 Pa. Code § 27.18(h)—(j) (relating to standards of practice). Refills shall be authorized by the licensed prescriber at the time the prescription is ordered. 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.
4. (d) Payment for prescribed nonlegend drugs shall be limited to drugs listed on the Department’s website.
5. (e) {Reserved}.
6. (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 individuals with intellectual disabilities 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 Human Services Code (62 P.S. § § 201, 403, 403.1 and 443.4); § 1121.53(c) abrogated in part under section 2(4) of the act of October 28, 2022 (P.L. 1632, No. 98).

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; § 1121.53(c) abrogated in part October 28, 2022 (P.L. 1632, No. 98); amended January 2, 2026, effective January 3, 2026, 56 Pa.B. 16. Immediately preceding text appears at serial pages (422712) to (422715).

(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 § 1121.56a (relating to drug cost determination).