55 Pa. Code § 1121.55 – Method of payment.

(a) The Department will pay a pharmacy for a compensable legend and nonlegend drug (after deducting the applicable copayment amount, as described in § 1101.63(b) (relating to payment in full)), the lower of the following amounts:
1. (1) The drug cost for brand name and generic drugs, including the ingredients of compounded drugs, as determined by § 1121.56a (relating to drug cost determination), multiplied by the number of units dispensed, plus a $10 professional dispensing fee.
2. (2) {Reserved}.
3. (3) The provider’s usual and customary charge to the general public.
4. (4) For MA recipients with a pharmacy benefit resource which is a primary third party payer to MA, the drug cost as determined by § 1121.56a, multiplied by the number of units dispensed, plus a $0.50 dispensing fee.
(b) {Reserved}.
(c) The provider shall bill the Department at its usual and customary charge to the general public.

Authority

The provisions of this § 1121.55 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).

Source

The provisions of this § 1121.55 amended August 10, 1984, effective September 1, 1984, 14 Pa.B. 2926; 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 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 September 22, 1995, effective October 1, 1995, 25 Pa.B. 3978; 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 (422717) to (422718).

(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 6 Pa. Code § 22.11 (relating to general payment principles); 49 Pa. Code § 27.505 (relating to repositories); and 55 Pa. Code § 1121.51 (relating to general payment policy).