CHAPTER 4220. REIMBURSEMENT FOR MEDICATIONS

§ 4220.1. Purpose.

 The legal authority for this chapter is section 201(2) of the Mental Health and Mental Retardation Act of 1966 (50 P. S. §  4201(2)).

GENERAL REQUIREMENTS

§ 4220.11. Purchase of drugs.

 (a)  In order for the cost of a drug to be reimbursed by the county mental health and mental retardation program it must be prescribed by a practitioner licensed by statute to prescribe the drugs and must be specifically for the mental disorder under treatment. Client liability and third party revenues must be exhausted before county mental health and mental retardation funds are used.

 (a)  Drugs in the following general categories may be reimbursed by the county mental health and mental retardation program.

   (1)  Major tranquilizers. Includes:

     (i)   Phenothiazines.

     (ii)   Butyrophenones.

     (iii)   Thioxanthenes.

     (iv)   Rauwolfia Alkaloids.

     (v)   Dibenzoxazepines.

     (vi)   Molindones.

   (2)  Minor tranquilizers. Includes:

     (i)   Propanediole.

     (ii)   Benzodiazepines.

     (iii)   Diphenylmethane Derivatives.

   (3)  Hypnotics and sedatives. Includes:

     (i)   Barbiturates.

     (ii)   Nonbarbiturates.

   (4)  Antidepressants. Includes:

     (i)   Tricyclics.

     (ii)   Monomine Oxidase Inhibiters.

     (iii)   Lithium.

   (5)  Central nervous system stimulants.

   (6)  Anticonvulsant agents.

   (7)  Antiparkinsonian agents.

   (8)  Various geriatric psychotropic agents.

 (b)  The county mental health and mental retardation program may also reimburse for an item not falling in the general categories listed in subsection (a)(1)—(8), if in the licensed practitioner’s professional opinion, it is essential for the present treatment of the patient’s mental disorder. The county mental health and mental retardation program may require, as a condition of reimbursement for these items, that prior approval be given by the County MH/MR Program. Where prior approval is required, it is the responsibility of the county administrator to ensure that proper notification of approval be given to the pharmacy at the time the prescription is presented to be filled.

 (c)  An initial prescription is limited to a 45 day supply and a maximum of one refill may be requested on an initial prescription. The quantity dispensed on the refill prescription cannot exceed the quantity prescribed on the initial prescription.

 (d)  The County MH/MR Program’s maximum rate of reimbursement for drugs is the pharmacy’s usual and customary charges to the general public for psychotropic drugs. Discounts given to special groups such as senior citizens must also be given to County MH/MR clients who are members of those specialized groups.

 (a)  The prescription must be made on Prescription and Pharmacist’s Invoice, Form MH/MR 12. The number of refills permitted—not to exceed one—should be indicated on the MH/MR 12. It is the responsibility of the physician to ensure that the patient’s drug costs are eligible for reimbursement by the County MH/MR Program and have been authorized for payment by the county administrator before using an MH/MR 12 prescription form.

 (b)  The pharmacy submits the MH/MR 12 on a monthly basis to the county MH/MR administrator for reimbursement. Refills of prescriptions should be reported to the county program on a monthly basis on a form of the county program’s choosing.

 (a)  It is the responsibility of the county administrator to ensure that the cost of the county program’s drug program is kept at an acceptable level and is of professional quality. The county program should establish procedures to ensure that poor prescribing and dispensing practices are eliminated or controlled, and to assist in the continuing education of physicians and pharmacists participating in the county program. In order to ensure maximum acceptance of these procedures, they should be under the direction and guidance of physicians and pharmacists under contract with the county program where possible.

 (b)  A county spending more than $50,000 per year on drugs shall have a Pharmacy and Therapeutics Review Committee (PTRC) composed of at least a psychiatrist, another physician, a pharmacist, and a representative of the county administrator’s office. The PTRC should be of sufficient size to permit a broad representation of viewpoints. Use of a PTRC by a county program spending less than $50,000 per year is optional at the discretion of the county program. The PTRC in a county spending less than $50,000 per year must be composed of at least one psychiatrist, one pharmacist, and a representative of the county administrator’s office. A county program may combine resources with another county program to develop a PTRC to serve the county programs involved.

 (c)  Quality control is the primary function of the PTRC. Through use of the following quality control procedures, significant improvements in the quality of the prescribing and dispensing of medications should be realized in the county program. The following quality control functions should be performed by a PTRC:

   (1)  Recommendation of guidelines for psycho-pharmacological treatment within the county programs. Guidelines should address issues as: polypharmacy, generic drug dispensing and prescribing, county formulary of reimbursable drugs, prescription quantities and refills, prior approval, and post-audit policies.

   (2)  Periodic review of the county drug program for patterns of overutilization or drug abuse by patients, inefficient and costly methods of prescribing drugs, inefficient and costly methods of dispensing drugs, or noncompliance with guidelines. When problems are identified the information should be shared with the physician or pharmacist by letter or by personal contact.

   (3)  Continuing education rather than restrictive actions, is the primary function of the PTRC.

 (d)  The following cost control measures are available to county programs when taken in consultation with a county PTRC. These measures should only be used when limited resources cause expenditure on medication to impact adversely on other service areas. Caution should be exercised in the use of these measures. The goal of the PTRC program should be to ensure cost benefit and sound practice in the county drug program, while at the same time permitting flexibility, easy access by clients, and encouraging the private model of human service delivery and of the dispensing of drugs.

   (1)  The county program may establish a formulary of drugs for which it will reimburse and may exclude from that formulary specific drugs or classes of drugs even though they fall in the general categories in §  4220.12(a) (relating to limitations). A county drug formulary must be published at least annually in a newspaper or papers having side circulation in the county program service area.

   (2)  The county program may establish limits on the total allocation or dollar amount for which it will reimburse.

   (3)  The county program may require prior approval or post-reveiw by the PTRC in order for reimbursement to occur. Post-review procedures are to be preferred to prior approval procedures and should be used where possible.

   (4)  The county program may limit the number of refills to less than one refill, or limit the number of days to fewer than 45 days. The maximum limits under §  4220.12(c) may not be exceeded.

   (5)  The county program PTRC may conduct a review or audit of pharmacies participating in the Mental Health/Mental Retardation (MH/HR) drug program to ensure that charges made by the pharmacy to the county program are the usual and customary charges of the pharmacy to the general public.

   (6)  Where any of the cost control measures under this subsection are enacted, the county administrator must make provision for appeals by prescribers, pharmacies or providers on a ‘‘special case’’ basis.

   (7)  Cost control measures enacted by county programs under this subsection are subject to review and approval by the Department.