Payment will not be made to a pharmacy for the following services and items:

1. (1) Drugs, services or other items not compensable under the Medicaid State Plan.
2. (2) Nonlegend drugs in the form of troches, lozenges, throat tablets, cough drops, chewing gum, mouthwashes and similar items.
3. (3) Pharmaceutical services provided to a hospitalized person.
4. (4) Drugs and devices classified as experimental by the FDA or whose use is classified as experimental by the FDA.
5. (5) Drugs and devices not approved by the FDA or whose use is not approved by the FDA.
6. (6) Placebos.
7. (7) Nonlegend dentifrices, mouthwashes, douche solutions, deodorants, liniments and other personal care and medicine chest items.

8. (8) Compounded prescriptions when one of the following applies:

   1. (i) Compensable items are used in less than therapeutic quantities.
   2. (ii) Noncompensable items are compounded.
9. (9) Nonlegend drugs not listed as compensable pharmaceutical services on the Department’s website as specified in § 1121.53(d) (relating to limitations on payment).
10. (10) Drugs prescribed in conjunction with noncompensable procedures.

11. (11) The following items when prescribed for recipients in a skilled nursing facility, an intermediate care facility or an intermediate care facility for individuals with intellectual disabilities:

    1. (i) Intravenous solutions.
    2. (ii) Noncompensable drugs and items as specified in this section.

    3. (iii) The following nonlegend drugs:

       1. (A) Analgesics.
       2. (B) Antacids.
       3. (C) {Reserved}.
       4. (D) Cough-cold preparations.
       5. (E) Contraceptives.
       6. (F) Laxative and stool softeners.
       7. (G) Ophthalmic preparations.
       8. (H) Diagnostic agents.
    4. (iv) Legend laxatives.
12. (12) Items prescribed or ordered by a prescriber who has been barred or suspended from participation in the MA Program. The list of providers precluded from participation in the MA Program will be posted on the Department’s website. Pharmacies are responsible for checking this list before filling prescriptions.
13. (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). Pharmacies are responsible for checking the Eligibility Verification System (EVS) to determine if the recipient is restricted to a specific provider before filling the prescription.
14. (14) DESI drugs and identical, similar or related products or combinations of these products.
15. (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/developmental services programs as specified in § 1121.51 (relating to general payment policy).
16. (16) FDA approved pharmaceutical products whose indicated use is not to treat or manage a medical condition, illness or disorder.
17. (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 1927 of the Social Security Act (42 U.S.C. § 1396r-8), except for those specific drug products authorized by the Federal government as essential to the health of an MA recipient. The Department will issue and post on the Department’s website revisions to the list of those companies that participate in the Federal Drug Rebate Program.
18. (18) {Reserved}.
19. (19) Erectile dysfunction drugs unless used for an FDA approved indication other than for the treatment of sexual or erectile dysfunction.
20. (20) Agents when used to promote fertility.
21. (21) Agents used for cosmetic purposes or hair growth.

Authority

The provisions of this § 1121.54 amended under sections 201(2), 403(b) and 403.1 of the Human Services 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; amended January 2, 2026, effective January 3, 2026, 56 Pa.B. 16. Immediately preceding text appears at serial pages (422715) to (422717).

Cross References

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