Payment for Prescription Drugs

(1) Payment for Multiple Source Drugs. Payment for multiple source drugs not designated as Brand Name Preferred and not certified as medically necessary (i.e., drugs for which the prescriber has not designated “no substitution” and “brand name medically necessary” on the prescription form), other than blood clotting factor and drugs obtained through the 340B Drug Pricing Program, must not exceed the lowest of (a) the Federal Upper Limit of the drug, if any, plus the appropriate dispensing fee as listed in 101 CMR 331.06; or (b) the Massachusetts Maximum Allowable Cost of the drug, if any, plus the appropriate dispensing fee as listed in 101 CMR 331.06; or (c) the AAC of the drug, plus the appropriate dispensing fee as listed in 101 CMR 331.06; or (d) the usual and customary charge. (2) Payment for Blood Clotting Factor. Payment for blood clotting factor not obtained through the 340B Drug Pricing Program must not exceed the lowest of (a) the Federal Upper Limit of the drug, if any, plus the appropriate dispensing fee as listed in 101 CMR 331.06; or (b) the AAC of the drug, plus the appropriate dispensing fee as listed in 101 CMR 331.06; or (c) 106% of the Average Sales Price of the drug, plus the appropriate dispensing fee as listed in 101 CMR 331.06; or (d) the usual and customary charge. (3) Payment for All Other Drugs. Payment for all other drugs not priced in accordance with 101 CMR 331.04(1) or (2), and not obtained through the 340B Drug Pricing Program, including single source drugs, multiple source drugs designated as Brand Name Preferred, and brand name drugs which have been certified as medically necessary (i.e., drugs for which the prescriber has designated “no substitution” and “brand name medically necessary” on the prescription form), must not exceed the lowest of: (a) The Massachusetts Maximum Allowable Cost of the drug, if any, plus the appropriate dispensing fee as listed in 101 CMR 331.06; or (b) The AAC of the drug, plus the appropriate dispensing fee as listed in 101 CMR 331.06; or (c) The usual and customary charge. (4) Rate Limitation. (a) Payments for multiple source drugs for which CMS has established Federal Upper Limits, and that have not been certified as medically necessary (i.e., drugs for which the prescriber has not designated “no substitution” and “brand name medically necessary” on the prescription form), must not exceed, in the aggregate and prior to the application of an federal or state drug rebates, the aggregate upper limit based on those Federal Upper Limits, regardless of whether payment amounts for individual drugs are determined pursuant to 101 CMR 331.04(1) or 101 CMR 331.04(3). (b) Payments for multiple source drugs that have been certified as medically necessary (i.e., drugs for which the prescriber has designated “no substitution” and “brand name medically necessary” on the prescription form), must not exceed, in the aggregate and prior to the application of an federal or state drug rebates, the lower of AAC plus the appropriate dispensing fee as listed in 101 CMR 331.06 and the usual and customary charge.