S.D. Admin. R. 67:16:14:06

Current through Register Vol. 51, page 57, November 12, 2024

Section 67:16:14:06 - Payment for items dispensed by pharmacy

Payment for items covered under this chapter and dispensed by a pharmacy is made at the lowest of the following: The provider's usual and customary charge;

(1) The estimated acquisition cost of the drug dispensed, plus a dispensing fee contained on the department's fee schedule website;

(2) The payment limit established by the United States Department of Health and Human Services under the provisions of 42 C.F.R. § 447.332 (July 1, 1987) for multiple-source drugs, plus a dispensing fee contained on the department's fee schedule website; or

(3) The payment limit established by the department, in consultation with the contractor, for drugs contained on the state MAC list, plus a dispensing fee contained on the department's fee schedule website.

For purposes of this section, the provider's usual and customary charge is that charge made by the provider to third-party payers for a specific item on the day the item is supplied.

S.D. Admin. R. 67:16:14:06

SL 1975, ch 16; 42 SDR 51, effective 10/13/2015

General Authority: SDCL 28-6-1, 28-6-1.1.

Law Implemented: SDCL 28-6-1, 28-6-1.1.

Upper limits for multiple-source drugs, 42 C.F.R. § 447.332 . Payment for drugs dispensed by physician, § 67:16:14:06.06. Payment for drugs dispensed by PHS provider, § 67:16:14:06.09. Federal drug list, http://www.cms.hhs.gov/home/medicaid.asp. State MAC list, Departments pharmacy website.