Md. Code Regs. 10.11.03.18

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.11.03.18 - Billing Procedures for Pharmacy Services

A. A pharmacy provider shall comply with all procedures listed in Regulation .13 of this chapter.

B. A pharmacy provider shall:

(1) Upon request, produce records to verify any charge to the CMS Program; and

(2) Charge the CMS Program the usual and customary charge to the general public for similar prescriptions.

C. Determination of allowable cost for multiple source drugs designated by the Centers for Medicare and Medicaid Services of the Department of Health and Human Services or for each drug listed in the formulary allowable cost shall be the lowest of the maximum allowable cost.

D. Payment for covered services to a pharmacy shall be made as follows:

(1) Payment for formulary drug preparation shall be the:

(a)-(b) (text unchanged)

(2) Payment for over-the-counter drugs is not covered except in extenuating circumstances at the discretion of the CMS Program

(3) Payment for medical supplies and durable equipment shall be the:

(a) Most cost-efficient; or

(b) Maximum limit established by the Department based upon the lowest price at which the product is generally available throughout the State.

E. In order to determine whether the current professional fee is appropriate, the Department shall periodically conduct surveys to determine the actual costs involved in filling a prescription in the State.

Md. Code Regs. 10.11.03.18

Regulations .18 adopted effective November 28, 1988 (15:24 Md. R. 2769)
Regulations .18 amended and recodified from Regulation .25 effective 42:7 Md. R. 568, eff.4/13/2015