California Welfare and Institutions Code 14105.455 – (a) Pharmacy providers shall submit their usual and customary …
(a) Pharmacy providers shall submit their usual and customary charge when billing the Medi-Cal program for prescribed drugs.
(b) “Usual and customary charge” means the lower of the following:
Terms Used In California Welfare and Institutions Code 14105.455
- department: means the State Department of Health Services. See California Welfare and Institutions Code 14062
- Medi-Cal: means the California Medical Assistance Program. See California Welfare and Institutions Code 14063
(1) The lowest price reimbursed to the pharmacy by other third-party payers in California, excluding Medi-Cal managed care plans and Medicare Part D prescription drug plans.
(2) The lowest price routinely offered to any segment of the general public.
(c) Donations or discounts provided to a charitable organization are not considered usual and customary charges.
(d) Pharmacy providers shall keep and maintain records of their usual and customary charges for a period of three years from the date the service was rendered.
(e) Payment to pharmacy providers shall be the lower of the pharmacy’s usual and customary charge or the reimbursement rate pursuant to subdivision (b) of Section 14105.45.
(f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of a provider bulletin or notice, policy letter, or other similar instructions, without taking regulatory action.
(Amended by Stats. 2011, Ch. 29, Sec. 16. (AB 102) Effective June 29, 2011.)