Ill. Admin. Code tit. 89, § 140.440 - Pharmacy Services
a)
Payment shall be made only to pharmacies.
b) The following conditions apply to pharmacy
participation:
1) The pharmacy must hold a
current Drug Enforcement Administration (DEA) registration issued by the United
States Drug Enforcement Administration (see 21 CFR 1301 et seq.), as well as a
current controlled substances license issued by the Illinois Department of
Financial and Professional Regulation (see Controlled Substances Act [720 ILCS
570]) prior to enrolling with the Department.
2) Licensed Pharmacy Requirements
A) A licensed pharmacy located in and/or
administratively associated with a group practice or long-term facility must:
i) provide the same scope of general pharmacy
and professional services as a pharmacy not so affiliated; and
ii) be retail in nature, open and accessible
to the general public.
B)
The pharmacy shall not limit prescriptions filled to those written by
practitioners connected with the group or facility for persons receiving care
or services from the group or facility.
3) A hospital pharmacy that provides
pharmaceutical services and supplies for inpatients, outpatient clinic patients
and emergency room patients of the hospital may not enroll as a participating
pharmacy unless licensed to provide pharmaceutical services to the general
public (Division 5 license).
4)
Effective August 1, 2012, in order to dispense blood factor, a pharmacy must
sign a standards of care agreement with the Department.
5) A pharmacy billing the Department for
340B-purchased drugs shall charge the Department no more than its actual
acquisition cost (AAC) for the drug product plus the Department's established
dispensing fee, unless the Department has calculated an allowable amount
specific to 340B-purchased drugs for that drug. In that case, the pharmacy may
bill the Department its usual and customary charges. For a pharmacy provider
owned or operated by a Hemophilia Treatment Center, this requirement does not
become effective until July 1, 2013.
c) The Department shall pay for the
dispensing of pharmacy items, subject to the provisions of subsection (d) and
Section
140.443,
which are prescribed by a physician, dentist or podiatrist within the scope of
their professional practice.
d)
Beginning with drugs dispensed on or after April 1, 1991, Department coverage
shall be limited to those drug manufacturers having rebate agreements in effect
as provided under section 1927 of Title XIX of the Social Security Act (
42 USC
1396s) . The Department shall provide all
interested parties with an updated list of drug manufacturers having rebate
agreements in effect.
e) The
Department may require approval for the reimbursement of any drug except as
provided in Section
140.442.
When reviewing requests for prior authorization, approval decisions shall be
medically based. The Department's electronic claims processing system shall be
the mechanism for identification of whether a prescribed drug requires prior
authorization to dispensing pharmacists. A printed listing of prescribed drugs
available without prior approval shall be provided to other interested parties
upon request.
f) An approved
request does not guarantee payment. The recipient for whom the services/items
are approved must be eligible at the time they are provided. In addition, a
valid, current prescription for the requested medication must be on file and
maintained by the pharmacy in accordance with the Pharmacy Practice Act [225
ILCS 85].
g) For purposes of
Sections 140.440 through
140.448,
pertaining to reimbursement for drugs, the following definitions apply:
1) Nursing facility means any facility that
provides medical group care services as defined in Section
140.500.
2) Generic drug means those legend drugs that
are multiple source drugs marketed or sold by two or more labelers, marketed or
sold by the same labeler under two or more different proprietary names or
marketed both under a proprietary name and without such a name.
3) Brand name drug means single-source
innovator drugs and innovator multiple-source drugs when prior authorization
has been obtained for reimbursing the innovator product.
h) The Department will cover hormone therapy,
whether or not in preparation for gender-affirming surgery, in accordance with
Section 140.442.
Notes
Amended at 37 Ill. Reg. 10282, effective June 27, 2013
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