The purpose of the amendment to Rule 59G-4.251, Florida Administrative Code (F.A.C.), is to add definitions and update the dispensing fee for prescribed drugs service providers. The amendment specifies the dispensing fee used in the calculation of ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-4.251Prescribed Drugs Reimbursement Methodology

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-4.251, Florida Administrative Code (F.A.C.), is to add definitions and update the dispensing fee for prescribed drugs service providers. The amendment specifies the dispensing fee used in the calculation of the reimbursement methodology, and adds definitions to clarify terms referenced in the rule.

SUBJECT AREA TO BE ADDRESSED: Prescribed Drugs Payment Methodology.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.906, 409.908, 409.912 FS.

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

DATE AND TIME: August 28, 2017,10:00 a.m. to 10:30 a.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, 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: Kym Holcomb. 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: Kym Holcomb, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone] e-mail: [e-mail].

Please note that a preliminary draft of the reference material, if available, will be posted prior to the workshop at http://ahca.myflorida.com/Medicaid/review/index.shtml. Official comments to be entered into the rule record will be received until 5:00 p.m. on August 29, 2017 and may be e-mailed to [e-mail]. For general inquiries and questions about the rule, please contact the person specified above.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

59G-4.251 Prescribed Drugs Reimbursement Methodology.

(1) This rule applies to all prescribed drug service providers enrolled in the Florida Medicaid program that provide services under the fee-for-service delivery system in accordance with Rule 59G-4.250, F.A.C.

(2) Definitions.

(a) Actual Acquisition Cost for Prescribed Drugs – (AAC) –The National Average Drug Acquisition Cost (NADAC) will be used for the AAC, when available. If the NADAC is unavailable, the AAC will be equal to the wholesaler acquisition cost.

(b) Federal Upper Limit of Payment – (FUL) – The rate of payment established by the federal Centers for Medicare and Medicaid Services (CMS) for multiple source drugs.

(c) State Maximum Allowable Cost – (SMAC) – The maximum allowable unit cost established by the state; SMAC may be manually set.

(d) Usual and Ccustomary Ccharge ‒ (UAC) ‒ The average charge to all other members of the general public, paying cash, customers in any quarter for the same drug, quantity, and strength.

(e) Wholesaler Acquisition Cost ‒ (WAC) – The cost wholesalers pay for a prescribed drug.

(3) Reimbursement Methodology.

(a) Florida Medicaid reimburses for covered drugs dispensed by an approved Florida Medicaid pharmacy provider, or a provider enrolled as a dispensing practitioner, in an amount not to exceed the lesser of:

1. The AAC plus a professional dispensing fee of $10.24.

2. The WAC plus a professional dispensing fee of $10.24.

3. The SMAC plus a professional dispensing fee of $10.24.

4. The provider’s UAC.

(b) The above reimbursement methodology applies to all of the following:

1. Brand and generic drugs.

2. Specialty drugs dispensed primarily through the mail.

3. Drugs not purchased pursuant to the 340B program by a covered entity.

4. Drugs acquired via the Federal Supply Schedule (FSS).

5. Drugs acquired at a nominal price (except for drugs purchased through the 340B program or FSS).

6. Drugs dispensed in an institutional or long-term care pharmacy, when not included as part of an inpatient stay.

7. Drugs dispensed by a retail community pharmacy.

8. Drugs that are prohibited from generic substitution in accordance with Rule 64B16-27.500, Florida Administrative Code.

(4) Florida Medicaid reimburses for drugs purchased under the 340B program at the actual purchased drug price, not to exceed the 340B ceiling price, plus a dispensing fee of $10.24. This provision applies to covered entities, outpatient facilities, Indian Health Services, tribal organizations and urban Indian pharmacies, and federally qualified health centers or their contracted agents that dispense drugs purchased at prices authorized under section 340B of the Public Health Service Act.

(5) Florida Medicaid reimburses for clotting factor to the vendors awarded the state’s hemophilia contract at the negotiated price.

(6) Florida Medicaid reimburses for covered prescribed drugs administered by a licensed practitioner in an office setting at WAC.

(7) Florida Medicaid reimburses for covered prescribed drugs administered in an outpatient facility at WAC.

reimburses for services in accordance with the provisions of Title 42, Code of Federal Regulations, sections 447.512-.516. Reimbursement amounts shall not exceed the lesser of:

(a) The wholesaler acquisition cost (WAC) plus 1.5%, plus a dispensing fee of $3.73.

(b) The federal upper limit (FUL) established by the Centers for Medicare and Medicaid Services, plus a dispensing fee of $3.73.

(c) The state maximum allowable cost (SMAC), plus a dispensing fee of $3.73.

(d) The provider’s usual and customary (U&C) charge, including the dispensing fee.

(e) The actual acquisition cost, plus a dispensing fee of $7.50. This provision only applies to covered entities and federally qualified health centers or their contracted agents that dispense or administer drugs purchased at prices authorized under section 340B of the Public Health Service Act.

Rulemaking Authority 409.919 FS. Law Implemented 409.906, 409.908, 409.912 FS. History–New 1-28-09, Amended 8-23-09, 5-20-12, 6-2-16,         .