No. 41916 (Amendment): Section R414-60-7. Reimbursement

(Amendment)

DAR File No.: 41916
Filed: 07/10/2017 11:07:58 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to update the dispensing fee for pharmacies located outside of the state of Utah, to be in accordance with the Medicaid State Plan.

Summary of the rule or change:

This amendment updates the dispensing fee for pharmacies located outside of the state of Utah, in accordance with the Medicaid State Plan.

Statutory or constitutional authorization for this rule:

• 42 CFR 447.502 through 447.520
• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only updates by rule the dispensing-fee provision for out-of-state pharmacies, which has been implemented through the Medicaid State Plan.

local governments:

There is no impact to local governments because they do not fund pharmacy services under the Medicaid program.

small businesses:

There is no impact to small businesses because this change only updates by rule the dispensing-fee provision for out-of-state pharmacies, which has been implemented through the Medicaid State Plan.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers and to Medicaid members because this change only updates by rule the dispensing-fee provision for out-of-state pharmacies, which has been implemented through the Medicaid State Plan.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to Medicaid member because this change only updates by rule the dispensing-fee provision for out-of-state pharmacies, which has been implemented through the Medicaid State Plan.

Comments by the department head on the fiscal impact the rule may have on businesses:

After conducting a thorough analysis, it was determined that this proposed rule will not result in a fiscal impact to businesses.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/31/2017

This rule may become effective on:

10/01/2017

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-60. Medicaid Policy for Pharmacy Program.

R414-60-7. Reimbursement.

(1) A pharmacy may not submit a charge to Medicaid that exceeds the pharmacy's usual and customary charge.

(2) Covered-outpatient drugs are reimbursed at the lesser of the following:

(a) The Wholesale Acquisition Cost;

(b) The Federal Upper Limit assigned by the Centers for Medicare and Medicaid Services;

(c) The Utah Maximum Allowable Cost; and

(d) The submitted ingredient cost.

(e) If a prescriber obtains prior authorization for a brand-name version of a multi-source drug in accordance with 42 CFR 447.512 or if a brand-name drug is covered because a financial benefit will accrue to the State in accordance with Section 58-17b-606, then Medicaid will not apply the Utah Maximum Allowable Cost or Federal Upper Limit to the claim.

(f) Pharmacies participating in the 340B program and using medications obtained through the 340B program to bill Medicaid must submit the actual acquisition cost of the medication on the claim.

(g) Pharmacies that participate in the Federal Supply Schedule and use medications obtained through the schedule to bill Utah Medicaid, must submit the actual acquisition cost of the medication on the claim unless the claim is reimbursed as a bundled charge or All Inclusive Rate.

(h) Pharmacies that obtain and use medications at a nominal price must submit the actual acquisition cost of the medication on the claim.

(i) The Utah Maximum Allowable Cost (UMAC) for drugs for which the Centers for Medicare and Medicaid Services (CMS) publishes a National Average Drug Acquisition Cost (NADAC), is the NADAC itself. The UMAC for which CMS does not publish a NADAC is calculated by the Department.

(3) Dispensing fees are as outlined in the Utah State Plan, Attachment 4.19-B as approved by CMS and as follows:

(a) [$9.99 for urban pharmacies in Utah;

(b) $10.15 for rural pharmacies in Utah;

(c) $7.66 for pharmacies located in a state other than Utah;

(d) $716.54 for hemophilia clotting factor dispensed by the contracted provider.

(e) ]Medicaid will pay the lesser of the assigned dispensing fee or the submitted dispensing fee;

([f]b) Medicaid will only pay one dispensing fee per 24 days per covered outpatient drug per pharmacy.

(4) Medicaid will pay the lesser of the sum of the allowed amount for the covered outpatient drug and dispensing fee or the billed charges.

(5) Immunizations provided to Medicaid clients who are at least 19 years of age will be paid for the cost of the immunization plus a dispensing fee. Medicaid will pay the lesser of the allowed or submitted charges.

(6) Immunizations provided to Medicaid clients who are 18 years old or younger will only be eligible for a dispensing fee with no reimbursement for the immunization. Immunizations for Medicaid clients who are 18 years old or younger must be obtained through the Vaccines for Children program.

(7) Blood glucose test strips listed as preferred on the Utah Medicaid Preferred Drug List will be reimbursed at the lesser of the Wholesale Acquisition Cost with no dispensing fee or the billed charges.

(8) In accordance with the Utah Medicaid State Plan, the Department may only reimburse a single-contracted provider for the purchase of hemophilia clotting factor.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [April 1], 2017

Notice of Continuation: April 30, 2012

Authorizing, and Implemented or Interpreted Law: 26-18-3; 26-1-5

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