Section 140.414  Requirements for Prescriptions and Dispensing of Pharmacy Items – Prescibers

For the purpose of this Section, "prescriber" shall mean any person who, within the scope of his or her professional licensing requirements, may prescribe or dispense drugs.

a)         Prescriptions

1)         A prescriber may prescribe any pharmacy item, not otherwise excluded, that, in the prescriber's professional judgment, is essential for the diagnosis or accepted treatment of a recipient's present symptoms.  The Department may require prior approval of any drug except as outlined in Section 140.442(a)(9).

2)         A prescriber shall:

A)        Use a tamper-resistant prescription form, as defined at Section 140.443(b)(2), for non-electronic prescriptions.  Non-electronic prescriptions are defined at Section 140.443(b)(1).  In addition, the prescriber shall ensure the prescription form is compliant with Section 3(e) of the Pharmacy Practice Act of 1987 [225 ILCS 85/3(e)], 68 Ill. Adm. Code 1330 and 42 USC 1936(i)(23); and

B)        Enter on the form all data elements required under Section 3(e) of the Pharmacy Practice Act of 1987 [225 ILCS 85/3(e)], 68 Ill. Adm. Code 1330 and 42 USC 1936(i)(23), as well as one of the following data elements identifying the prescriber:

i)         Drug Enforcement Administration (DEA) Number; or

ii)        National Provider Indentifier (NPI); or

iii)       Medical Assistance Program Provider Number; or

iv)       Illinois State License Number.

3)         The prescriber shall not charge for writing a prescription.

4)         Items that shall not be prescribed are listed in Section 140.441.

b)         Dispensed Items

1)         A participating prescriber may dispense pharmacy items subject to the Department's coverage policies.  The prescriber shall not charge for any samples dispensed or anesthesia agents administered for office surgical procedures.

2)         Effective July 1, 2012, the Department shall pay for covered outpatient drug items dispensed or administered by a non-pharmacy provider at a rate equal to the lowest of the provider's usual and customary charge to the public; or

A)        The Average Sales Price (ASP) plus 6 percent.  ASP means the ASP as defined in the Social Security Act, Title XVIII, section 1847A(c) (42 USC 1395 w-3a(c)) and calculated by the federal Centers for Medicare and Medicaid Services (CMMS); or

B)        The State upper limit.

3)         Effective July 1, 2012, in cases in which ASP is not available and no State upper limit has been developed, the Department's lowest maximum allowable price for all covered NDCs assigned to the HCPCS billing code (the methodology for determining the Department's maximum prescription prices is specified in Section 140.445(b)(1) and (b)(2)).

4)         Reimbursement rates for drugs dispensed or administered by non-pharmacy providers shall be updated no less frequently than twice per calendar year.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)