§140.445. Prescribed Drugs

a)         Effective July 15, 2019, for prescribed drugs, including prescription and over the counter drugs, the Department shall pay the lower of:

 

1)         the pharmacy's usual and customary charge to the general public;

 

2)         the Department's maximum price plus the established professional dispensing fee of $15.55 for drugs dispensed by Critical Access Pharmacies, as defined in this subsection, and $8.85 for drugs dispensed by non Critical Access Pharmacies.  The Department shall pay only one dispensing fee per 30 or greater days' supply for those drugs dispensed in accordance with Section 140.443(h). For purposes of this section, Critical Access Pharmacies are defined as pharmacies physically located within Illinois in counties with less than 50,000 residents; and whose owner(s) do not have ownership or control interest in ten (10) or more pharmacies; and which are brick and mortar, meaning the pharmacy location is open to the public, recipients present at the pharmacy to fill prescriptions, and the majority of the pharmacy's business is not mail order based or through delivery to a residential facility and which is not owned/operated by a hospital or located within a hospital.;

 

3)         The Department's maximum price is calculated as the lowest of:

 

A)        Wholesale Acquisition Cost (WAC) minus 17.5% for multiple source drugs; WAC minus 4.4% for brand name drugs; or WAC minus 10% for blood clotting factor; or

 

B)        National Average Drug Acquisition Cost, if available; or

 

C)        the Federal upper limit as established under section 1927(e)(4) of the Social Security Act (42 USC 1396r-8(e)(4)); or

 

D)        the State upper limit.

 

b)         Effective February 1, 2013, for generic and brand name drugs purchased under the federal drug pricing program established under Section 340B of the federal Public Health Services Act, the Department shall pay the actual acquisition cost for the drug, as billed by the provider, or the Department's established 340B allowable reimbursement rate for the drug, plus a professional dispensing fee of $12.00 for brand and generic drugs.

 

(Source:  Amended at 46 Ill. Reg. 2046, effective January 21, 2022)