Connecticut Administrative Code › Title 17 - Public Assistance and Welfare Services › 134d - Medical Assistance › Title XIX Rates for Community Health Centers › Section 17-134d-81 - Policy and procedures governing the billing and payment for prescription drugs on behalf of title XIX medicaid recipients

Current through July 10, 2024
(a)
Scope
This regulation governs the billing and payment for
				  prescription drugs and Pharmaceutical Services provided to persons determined
				  eligible for such goods and services under provisions of Connecticut's Medical
				  Assistance Program in accordance with Section 17-134d of the General Statutes
				  of Connecticut.
(b)
Definitions
For the purpose of Regulation Section 17-134d-81, the
				  following definitions apply:
(1)
				"Average Wholesale Price" (A.W.P.) means the published wholesale price as
				determined by the Department from the price listed by one or more national
				publications recognized by the Department.
(2) "Brand Name/Trade Name" means the name
				assigned to a drug by the pharmaceutical innovator, i.e., manufacturer and/or
				distributor for the purpose of distribution to wholesalers or retailer, whether
				or not this name is registered in the United States Patent Office.
(3) A "Compounded Prescription" means two or
				more drugs mixed together and at least one ingredient must be a legend drug. A
				compounded prescription must include name, strength, and amount of each
				prescribed ingredient.
(4)
				"Connecticut Over-the-Counter Formulary" means the formulary of O.T.C.
				(nonlegend) drugs which are reimbursable by the Department.
(5) "Department" means the Connecticut
				Department of Income Maintenance.
(6) "Dispensing Fee" means an amount of money
				paid to a pharmacist for rendering a professional service involving the
				preparation and dispensing of a prescribed drug order by a licensed authorized
				practitioner.
(7) "Documented in
				Writing" means that the prescription has been handwritten, typed or computer
				printed. Computerized systems must meet all of the requirements of the
				Commission of Pharmacy Regulations Chapter 382 Sections 20-164b-1 through
				20-164b-11 for non-controlled drugs and Sections
				21a-244-1
				through
				21a-244-6
				for controlled drugs and as they may be amended from time to time. (Note:
				Record retention for all Medicaid claims extends to a five (5) year period per
				(g)(2) of this regulation.)
(8)
				"Drug Efficacy Study Implementation (DESI) Program" means the program through
				which the Food and Drug Administration has identified certain products which
				lack sufficient evidence of their effectiveness for the approved
				indication(s).
(9) "Estimated
				Acquisition Cost" (E.A.C.) means the Department's best estimate of the price
				generally and currently paid by providers for a drug marketed or sold by a
				particular manufacturer or labeler in the package size most frequently
				purchased by providers.
(10)
				"Federal Acquisition Cost/Federal Upper Limit" (F.A.C.) means the upper limit
				allowable cost established and published by HCFA for those multiple source
				drugs which appear on HCFA's list of multiple source drugs for which upper
				limits have been established and as revised from time to time.
(11) "HCFA" means the Health Care Financing
				Administration of the United States Department of Health and Human
				Services.
(12) "Legend Drugs" means
				any article, substance, preparation or device which bears the legend: "Caution
				Federal Law prohibits dispensing without a prescription."
(13) "Licensed Authorized Practitioner" means
				any physician or other licensed practitioner who is authorized to prescribe
				drugs within the scope of his or her professional practice as defined and
				limited by Federal and State law.
(14) "Multiple-source Drug" means a drug
				marketed or sold by two or more manufacturers or labelers, or a drug marketed
				or sold by the same manufacturer or labeler under two or more different
				proprietary names, or both under a proprietary name and without such a
				name.
(15) "Nutritional
				Supplements" means commercially prepared products, the primary purpose of which
				is to treat a diagnosed deficiency or potential deficiency in the patient's
				diet or nutrition.
(16)
				"Over-the-Counter/Nonlegend Drugs" (O.T.C.) means drugs which do not require a
				prescription by Federal or State law (O.T.C. items are available for purchase
				by the general public with or without a prescription) and generally are used
				for persons residing in the community and is usually administered or used by
				the patient on the basis of self-diagnosis.
(17) "Pharmacy" means a facility licensed by
				the Commission of Pharmacy in the Department of Consumer Protection under
				Section 20-168 of the Connecticut General Statutes, or by the appropriate
				regulatory body of the state in which it is located.
(18) "Prescribed Drug" means a single drug or
				compound or mixtures or substances prescribed for the cure, mitigation, or
				prevention of disease, or for health maintenance that is:
(A) Prescribed by a licensed authorized
				practitioner within the scope of his or her professional practice as defined
				and limited by Federal and State law; and
(B) Dispensed by the licensed pharmacist on a
				written or oral prescription issued in accordance with the State Medical
				Practice Act and that is recorded and maintained in the pharmacist's
				records.
(19)
				"Prescription" means an order issued by a licensed authorized practitioner and
				documented in writing by either the practitioner or the pharmacist. In nursing
				homes the signed order of a licensed authorized practitioner will be accepted
				in lieu of a written or oral prescription. The written prescription includes:
(A) the name and address of the patient;
				and
(B) whether the patient is an
				adult or a child, or the patient's specific age; and
(C) the compound or preparation ordered;
				and
(D) its strength when
				applicable and the specific amount thereof, to be dispensed at one time;
				and
(E) directions for the use of
				the medication and any cautionary statements required; and
(F) the number of times that the prescription
				may be refilled, if applicable; and
(G) date of issuance; and
(H) name and address of the prescribing
				practitioner and his/her Drug Enforcement Act number when
				appropriate.
(20) "Prior
				Authorization" (P.A.) means approval for a service from the Department before
				the provider actually provides the services. In order to receive approval from
				the Department a provider must comply with all prior authorization requirements
				found in regulation. P.A. does not, however, guarantee payment unless all other
				eligibility requirements are met.
(21) "Usual and Customary Charge to the
				General Public" means a charge which will be made for the particular
				prescription by the provider to the patient group accounting for the largest
				number of non-Medicaid prescriptions. In determining such charge, all charges
				made to third party payors and special discounts offered to an individual such
				as a senior citizen will be excluded.