The purpose of the amendment to Rule 59G-4.251 is to modify the definition of estimated acquisition cost, relating to reimbursement for dispensing providers of covered drugs. The rule establishes the reimbursement methodology for prescribed drug ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-4.251Florida Medicaid Prescribed Drugs Reimbursement Methodology

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-4.251, F.A.C. is to modify the definition of estimated acquisition cost, relating to reimbursement for dispensing providers of covered drugs. The rule establishes the reimbursement methodology for prescribed drug claims in the Florida Medicaid program.

SUBJECT AREA TO BE ADDRESSED: Florida Medicaid Prescribed Drugs Reimbursement Methodology.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.906(20), 409.908, 409.912(39)(a) FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: June 11, 2015, 2:00 p.m. ‒ 3:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room B, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Arlene Elliott. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Arlene Elliott, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]

Comments will be received until 5:00 p.m., on June 18, 2015.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

59G-4.251 Florida Medicaid Prescribed Drugs Reimbursement Methodology.

(1) Reimbursement for prescribed drug claims is made in accordance with the provisions of Title 42, Code of Federal Regulations, sSections 447.512-.516. Reimbursement for covered drugs dispensed by a licensed pharmacy, approved as a Florida Medicaid provider, by an enrolled dispensing physician filling his own prescriptions, or by a medical professional administering injectable medications, shall not exceed the lower of:

(a) The estimated acquisition cost, defined as the lower of:

1. Average Wholesale Price (AWP) minus 16.4%, or Wholesaler Acquisition Cost (WAC) plus 1.5%, plus a dispensing fee of $3.73;

2. The Federal Upper Limit (FUL) established by the Centers for Medicare and Medicaid Services, plus a dispensing fee of $3.73; or

(b) The State Maximum Allowable Cost (SMAC), plus a dispensing fee of $3.73; or

(c) The provider’s Usual and Customary (U&C) charge, inclusive of dispensing fee.

(2) For drugs purchased by qualified entities under sSection 340B of the Public Health Service Act:

Covered entities and fFederally qQualified hHealth cCenters or their contracted agents that fill Florida Medicaid patient prescriptions with drugs purchased at prices authorized under sSection 340B of the Public Health Service Act must bill Florida Medicaid for reimbursement at the actual acquisition cost plus a dispensing fee of $7.50 for these drugs.

Rulemaking Authority 409.919 FS. Law Implemented 409.906(20), 409.908, 409.912(39)(a) FS. History–New 1-28-09, Amended 8-23-09, 5-20-12,________.